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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700734
Report Date: 02/25/2022
Date Signed: 02/25/2022 04:02:03 PM

Document Has Been Signed on 02/25/2022 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:EMERALD HOMEFACILITY NUMBER:
342700734
ADMINISTRATOR:RAGCHAA, BAYARMAAFACILITY TYPE:
735
ADDRESS:9053 OLD CREEK DRIVETELEPHONE:
(279) 333-4419
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 0DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Bayarmaa RagchaaTIME COMPLETED:
04:15 PM
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On 2/25/2022 at 2:40 PM, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Prior to entering the facility, LPA Truong called the facility and spoke to Administrator Bayarmaa Ragchaa whom confirmed the facility doesn’t have any clients and no one in the facility have any symptoms of COVID-19 in the last 10 days. LPA met with Administrator Bayarmaa Ragchaa and explained the purpose of today’s visit.

Administrator holds current certification #6033626735 and expires on 12/06/2022. The facility is licensed to serve four (4) ambulatory, of which 1 may be non-ambulatory in room #3. This facility has a census of 0. LPA toured the facility with Administrator Bayarmaa Ragchaa on 2/25/2022 at 2:50 PM.

LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. The hot water temperature was measured and is within the required regulation of 105 to 120 degrees Fahrenheit. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA also conducted the infection control domain tool.

Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: EMERALD HOME
FACILITY NUMBER: 342700734
VISIT DATE: 02/25/2022
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The facility mitigation plan was submitted to CCLD, and it was approved on 3/05/2021. Facility had Covid-19 posters throughout the facility, and has implemented Covid-19 mitigation plan.

Administrator was informed to send updated copies of the following documents to CCL within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) LIC610 Emergency Disaster Plan
(4) Proof of Current Liability Insurance
(5) Control of Property
(6) Copy of Administrator Certificate

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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