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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700734
Report Date: 03/07/2023
Date Signed: 03/08/2023 11:29:06 AM

Document Has Been Signed on 03/08/2023 11:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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:
(916) 829-5613
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 3DATE:
03/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Caregiver Bayarmaa RagchaaTIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPAs) Vincent Moleski and Jason Lund arrived unannounced on Tuesday, March 7, 2023 for an annual inspection. LPAs Moleski and Lund met with Bayarmaa Ragchaa and explained the purpose of the visit. One resident was home at the time of the inspection, while the other two residents were at day program.

Ragchaa's administrator certification expired on 12/6/22, and she is still awaiting renewal. The current active administrator is Jasmine G Cailing, a staff member who received certification as of 6/21/21. Cailing's certification number is 6003409735. The certification expires on 6/20/23.

The facility is licensed for a capacity of 4 ambulatory residents. One resident may be non-ambulatory in room #3, per the license.

LPAs Moleski and Lund toured the facility with Ragchaa. LPAs Moleski and Lund inspected the facility including the common areas, kitchen, dining area, client bedrooms, laundry room and outdoor area. LPAs Moleski and Lund observed the grounds to be clean and in good repair. LPAs Moleski observed sufficient furniture and lighting throughout the facility. LPAs Moleski and Lund observed bedrooms to be properly furnished with appropriate bedding and lighting. The hot water temperature was measured and was observed to be less than 120 degrees. Smoke and carbon detectors were in good repair. The facility's fire extinguisher and first aid kit were up to date.

LPAs Moleski and Lund interviewed R1.

LPAs Moleski and Lund reviewed files for R1, R2, S1, and S2.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: EMERALD HOME
FACILITY NUMBER: 342700734
VISIT DATE: 03/07/2023
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LPAs Moleski and Lund requested an updated LIC 500.

No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Ragchaa. .
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC809 (FAS) - (06/04)
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