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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601635
Report Date: 10/10/2024
Date Signed: 10/10/2024 02:26:38 PM


Document Has Been Signed on 10/10/2024 02:26 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:EMERALD CARE MANORFACILITY NUMBER:
374601635
ADMINISTRATOR:JEROLYN BANDOYFACILITY TYPE:
740
ADDRESS:2605 EMERALD PLACETELEPHONE:
(760) 743-5813
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 3DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Jamie Avellaneda, Lead CaregiverTIME COMPLETED:
02:35 PM
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On 10/10/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit/annual inspection. LPA greeted and granted entry by Caregivers Jocelyn and Jamie where LPA explained the purpose of today's visit. The facility has an approved hospice waiver for 2 with (0) residents currently receiving hospice services. At the time of the visit there was (3) staff and (2) residents present. Below are the observations made during today's visit:

The facility was observed to have a food supply that was sufficient. The medications, sharps, chemicals and other hazardous items were observed to be locked and inaccessible to residents in care. The hot water temperature was tested and found to be within regulatory limits measuring at 105.8 degrees Fahrenheit. The smoke and carbon monoxide detectors were tested and found to be operable, the fire extinguishers were fully charged and last serviced on 01/31/24. The facility was observed to have the required postings such as CCL complaint poster, LTCO poster, and personal rights.

During a tour of the exterior of the physical plant. The facility was observed to have a full tennis court, with three separate sheds on grounds that are being utilized for storage. LPA observed for there to be a bedroom inside the garage, that is being utilized by Staff #4 (S4) of the 1 of the 2 live in caregivers. The second caregiver Staff #2 (S2) reports sleeping on the couch. In addition the facility is utilizing video surveillance in the common areas hallways, dining area and exterior areas of facility.

The following items are to be submitted to the department by 5pm on or before Monday 10/14/24:
-Updated facility sketch to include the cameras, as well as the addition with the staff bedroom.
-Addendum to plan of operation stating that video surveillance will be utilized
-Consents from the residents and or their responsible party consenting and acknowledging that they have been notified that video surveillance is being utilized
-Updated LIC610E-Emergency Disaster plan, last update was in August 2019
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EMERALD CARE MANOR
FACILITY NUMBER: 374601635
VISIT DATE: 10/10/2024
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Records review: LPA conducted a file review that revealed the facility annual fees have not paid, they are due by 10/16/24. During today's visit LPA gave a reminder and provided the following PIN 373897 should theLicensee wish to pay the fees electronically. The facility was observed to have valid liability insurance.

Staff files were observed to have the required training's completed such as dementia, proof of Cardio Pulmonary Resuscitation and first aid training. All staff present were observed to have obtained health screenings, criminal record clearance and to be associated to the facility.

Resident files were observed to have recent medical assessments, appraisals (pre placement and needs and services appraisal), as well as admission agreements.

An exit interview was conducted and a copy of this report was provided to Jamie Avellaneda, Lead Caregiver.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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