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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881089
Report Date: 04/10/2024
Date Signed: 04/10/2024 03:05:39 PM

Document Has Been Signed on 04/10/2024 03:05 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:EMERALD BOARD & CAREFACILITY NUMBER:
361881089
ADMINISTRATOR/
DIRECTOR:		GREGORIO, HAZEL ANNEFACILITY TYPE:
735
ADDRESS:18106 RAYMOND CTTELEPHONE:
(909) 320-8141
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 3CENSUS: 2DATE:
04/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Anita GregorioTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 04/10/2024 at 12:10 PM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA Brown knocked on the door, pressed the doorbell and LPA walked around the home and did not observe any persons inside the home. At 12:15 PM, LPA Brown contacted Licensee/Administrator Hazel Gregorio, and Licensee/Administrator Gregorio stated that a staff will be notified to go to the facility. Licensee Gregorio called back at 12:23 PM and reported that a staff will be at the facility in 20 minutes. At 12:53 PM, Staff #2 (S2) arrived at the facility and LPA Brown gained access to the home. LPA Brown explained the purpose of today's visit to S2. Staff Anita Gregorio was contacted and arrived during the visit.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA Brown completed a walkthrough of the facility, review of records, P and I audit and medications audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed two (2) clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 71 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. However, water temperatures tested at 123.3 degrees Fahrenheit. Deficiency will be issued. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: EMERALD BOARD & CARE
FACILITY NUMBER: 361881089
VISIT DATE: 04/10/2024
NARRATIVE
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Posters such as; the personal rights, CCLD complaint poster, emergency disaster plan were posted in a common area. Medications were kept in secure cabinets inaccessible to clients. LPA Brown observed night light at the hallway leading to clients' shared bathroom. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions. However, LPA Brown observed cleaning solutions, chemicals, scissors and other sharp tools inside the shed at the backyard, not locked and accessible to clients in care. Deficiency will be issued.

Food Service: LPA observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA Brown reviewed client files for admission agreements, medical assessments/physician reports, Individual Program Plan (IPP). LPA Brown observed files reviewed were complete. LPA Brown also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed files reviewed were complete.

LPA Brown audited two(2) clients medications and no issues were observed. LPA Brown audited clients' P&I and observed no issue.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and Appeal Rights were discussed and copies were provided to staff Anita Gregorio.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/10/2024 03:05 PM - It Cannot Be Edited


Created By: Melody Brown On 04/10/2024 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: EMERALD BOARD & CARE
FACILITY NUMBER: 361881089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not locking the cleaning solutions, chemicals, scissors and other sharp tools in the shed at the backyard of the facility, making it accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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Licensee locked the cleaning solutions, chemicals, scissors and other sharp tools in the shed with a padlock during the visit.
Licensee stated to train all staff on CCR 80087(g) and submit proof of all staff training log to LPA Brown at POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/10/2024 03:05 PM - It Cannot Be Edited


Created By: Melody Brown On 04/10/2024 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: EMERALD BOARD & CARE
FACILITY NUMBER: 361881089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not regulating the hot water temperature to not less than 105 degrees F and not more than 120 degrees F as the hot water temperature measured at 123.3 degrees F which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee stated to regulate the hot water temperature to not less than 105 degrees F and not more than 120 degrees F and submit proof to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
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