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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002839
Report Date: 02/12/2024
Date Signed: 02/12/2024 01:15:17 PM


Document Has Been Signed on 02/12/2024 01:15 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Administrator, Kimi Costar TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived on 02/12/24 to conduct the annual inspection. LPA met with administrator, Kimi Costar and explained the purpose of today's visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (2) and staff files (2). Residents(2) and staff (2) files were found to be complete. LPA checked medications records for 2 residents and found no errors. Facility was clean and well organized. All required posting were observed.

LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use. Hot water temperature was observed to be 118 degrees F, which is within the regulation range of 105-120 degree. Inside temperature was 75 degree F.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 02/29/24.

No deficiencies were observed or cited per Title 22, CCR Regulations during this visit .
Exit interview conducted and copy of this report left at facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
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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