<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881089
Report Date: 09/08/2023
Date Signed: 09/08/2023 01:02:35 PM

Document Has Been Signed on 09/08/2023 01:02 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:EMERALD BOARD & CAREFACILITY NUMBER:
361881089
ADMINISTRATOR:GREGORIO, HAZEL ANNEFACILITY TYPE:
735
ADDRESS:18106 RAYMOND CTTELEPHONE:
(909) 320-8141
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 2CENSUS: 1DATE:
09/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Anita Gregorio, Direct Care StaffTIME COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Emerald Board and Care Adult Residential Facility unannounced to conduct an inspection for a capacity increase. LPA rang the doorbell and was greeted by Direct Care Staff, Anita Gregorio. LPA introduced self and stated purpose of the visit, LPA was granted entry.

Direct Care Staff accompanied LPA on a tour of the facility interior and exterior. Direct Care Staff expressed that Room #3 is the room to be utilized for the capacity increase. The room included all furniture as regulated.
Room #3 is currently occupied; it is projected to be available within one week's time. The facility was inspected and approved by the Fire Marshall on 7/27/23.

No deficiencies cited during this visit. An exit interview was conducted where this report was discussed, reviewed, then provided to Anita Gregorio.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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 1