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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002839
Report Date: 02/16/2022
Date Signed: 02/16/2022 03:18:18 PM


Document Has Been Signed on 02/16/2022 03:18 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:EMERALD ESTATE SENIOR LIVINGFACILITY NUMBER:
345002839
ADMINISTRATOR:COSTAR, KIMIFACILITY TYPE:
740
ADDRESS:7100 KENNETH AVETELEPHONE:
(916) 947-6155
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 0DATE:
02/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Kim Costar, AdministratorTIME COMPLETED:
03:30 PM
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On February 16, 2022, at 2pm, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived announced to conduct a Pre-Licensing Inspection. LPA met with Administrator Kimi Costar. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) An N-95 mask was worn.
The facility is a single floor facility and has 7 bedrooms and 3 bathrooms. It has a capacity of 6. The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 71 degrees.
LPA inspected the interior and the exterior of the facility including the common living spaces, resident's bedrooms and bathrooms, kitchen and dining room. In the kitchen area, Knives and sharp objects are locked and made inaccessible to the residents. The first aid kit was complete with scissors, thermometer, tweezers and a guide. The hot water temperatures were taken and measured degrees F. There’s appropriate lighting throughout the facility. Dining room, and areas designated for residents, were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident's bedrooms and bathrooms were toured. All Bedrooms had all the required items of furniture. Window screens appeared to be in good repair. Bathrooms were clean and sanitary. The sinks, toilets, showers and tub operate properly. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguishers are maintained and ready for emergency use.
LPA observed a medication room with locked cabinets and an area were files will be held. There are no medications or staff and client files available for review because the facility has no residents at this time.


To continue see 809-C
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: EMERALD ESTATE SENIOR LIVING
FACILITY NUMBER: 345002839
VISIT DATE: 02/16/2022
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LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. Indoor and outdoor passageways are free of obstruction and potential hazards. The porch and patio area have no potential hazards to residents.

At the time of this inspection, the facility is in compliance and meets the minimum requirements for residential care facility for the elderly.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit.

Application is pending further review.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2