374600431-10-20-2023-08-AS-DPEA-CWKTCW-20231013143725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600431
Report Date: 10/13/2023
Date Signed: 10/20/2023 07:36:53 AM

Document Has Been Signed on 10/20/2023 07:36 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	EMERALD GUEST HOME		FACILITY NUMBER:	374600431
ADMINISTRATOR:	PETRONILA ECHEVARRIA		FACILITY TYPE:	740
ADDRESS:	2558 MOBLEY STREET		TELEPHONE:	(858) 430-6093
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92123
CAPACITY:	3	CENSUS: 3	DATE:	10/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Petronila Echevarria, Licensee & Christian Atuel, Caregiver		TIME COMPLETED:	03:00 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 (LPA) Daniel Pena conducted an unannounced Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver, Christian Atuel. Administrator, Echevarria Petronila, later joined LPA. According to the facility’s license, the facility serves clients age 60 and above; ambulatory only. LPA Pena, toured the interior and exterior of the facility, and inspected each room. The facility was organized, kempt, in good repair and contained no offensive odors. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. There was at least two days of perishable food, and at least seven days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on the premises. Per Caregiver, no firearms or ammunition

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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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Document Has Been Signed on 10/20/2023 07:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: EMERALD GUEST HOME	FACILITY NUMBER: 374600431
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to all persons in care.
	POC Due Date: 11/01/2023
	Plan of Correction
1 2 3 4	Licensee agreed to obtain the required liability insurance and provide CCLD with a copy of the insurance policy with the required coverages by POC due date.

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to all persons in care.
	POC Due Date: 10/20/2023
	Plan of Correction
1 2 3 4	Licensee agreed to obain required certification training for all personnel providing care to resident and forward copies of current First Aid/CPR certifications to CCLD by POC due date.

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: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2023

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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: EMERALD GUEST HOME	FACILITY NUMBER: 374600431
	VISIT DATE: 10/13/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas.

Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC809-D pages). A Plan of Correction was jointly developed with administrator.

An exit interview was conducted with Administrator, Echevarria to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC809 (FAS) - (06/04)

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