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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600431
Report Date: 08/12/2024
Date Signed: 08/12/2024 05:36:54 PM


Document Has Been Signed on 08/12/2024 05:36 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:EMERALD GUEST HOMEFACILITY NUMBER:
374600431
ADMINISTRATOR:PETRONILA ECHEVARRIAFACILITY TYPE:
740
ADDRESS:2558 MOBLEY STREETTELEPHONE:
(858) 430-6093
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY:3CENSUS: 3DATE:
08/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Licensee Petronila EchevarriaTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Licensee Petronila Echevarria. According to the facility’s license, there may be a maximum of three (3) clients at any given time at the facility, all of which must be ambulatory. During today’s inspection, there were three (3) clients present. The facility does not feature delayed egress doors.

Licensee's interview showed: Licensee allowed S1 to work as an employee of the facility without a criminal background record clearance for more than five days.

One (1) deficiency was thus cited per California Code of Regulations, Title 22. An immediate civil penalty of $500 was assessed today for a Criminal Record Clearance violation (see attached LIC 421-BG).

An exit interview was done with Licensee Petronila Echevarria to whom a copy of this report, the LIC 809-D, the LIC421 IM, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Juliana BarfieldTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
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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Document Has Been Signed on 08/12/2024 05:36 PM - 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: EMERALD GUEST HOME
FACILITY NUMBER: 374600431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2024
Section Cited
CCR
87355(e)(1)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility obtain a California clearance or a criminal record exemption as required by the Department. Based on interview, the licensee did not comply with the section cited in which poses an immediate health, safety or personal rights risk to persons in care.

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Licensee will obtain a California Clearance as required by the department for S1 immediately. Licensee will provide proof of the clearance by sending a copy of clearance for S1 to LPA by 08/23/2024.

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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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Juliana BarfieldTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
LIC809 (FAS) - (06/04)
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