415600003-9-12-2024-14-AS-MHAN-D932P7-20240912173352

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600003
Report Date: 09/12/2024
Date Signed: 09/12/2024 05:37:16 PM

Document Has Been Signed on 09/12/2024 05:37 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	EMERALD RETIREMENT RESIDENCE		FACILITY NUMBER:	415600003
ADMINISTRATOR:	ISABELLE GIL		FACILITY TYPE:	740
ADDRESS:	717 WIDGEON COURT		TELEPHONE:	(650) 358-8868
CITY:	FOSTER CITY	STATE: CA	ZIP CODE:	94404
CAPACITY:	6	CENSUS: 5	DATE:	09/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	administrator, Isabelle Gil		TIME COMPLETED:	12:00 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	On September 12, 2024 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregivers, Maria Burgos and Ronaldo Marcos and LPA explained the purpose of today's visit. The administrator, Isabelle Gil arrived shortly thereafter and assisted with the visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables, Facility has 5 resident bedrooms (4 private rooms and 1 shared room), 1 staff room, 2 full- bathrooms, kitchen, and common areas. The facility observed to clean, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Hot water temperature was measured at 108- 119 degrees F. The emergency drills were reviewed. Central stored medication, toxins and sharps objects were locked and inaccessible to residents. Staff training records were reviewed to be adequate. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. A review of (5) resident files was conducted and noted on the LIC 858. A review of (2) staff files was conducted and noted on the LIC 859. During today's inspection, there are 3 residents present and 2 were attending the adult day program.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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 09/12/2024 05:37 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMERALD RETIREMENT RESIDENCE	FACILITY NUMBER: 415600003
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(4)

Criminal Record Clearance

(e) 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: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as staff R.M.is not associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2024
	Plan of Correction
1 2 3 4	The administrator will fax all the required documents to CCL by 9/13/2024 to complete the criminal background transfer process.

Type A

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the last emergency drill was conducted in Jan, 2024 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2024
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure emergency drills are conducted accordingly and in the plan, it shall indicate when an emergency drill will be conducted.

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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/12/2024 05:37 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMERALD RETIREMENT RESIDENCE	FACILITY NUMBER: 415600003
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as resident has bedrails by the head of the bed without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2024
	Plan of Correction
1 2 3 4	The administrator will develop a plan to obtain a physician's order for this resident and the plan shall indicate when the order will be obtained. The administrator will provide a copy of the plan to CCL by 9/13/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMERALD RETIREMENT RESIDENCE	FACILITY NUMBER: 415600003
	VISIT DATE: 09/12/2024

NARRATIVE

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During the tour, LPA observed a storage unit in the yard and inside the storage unit, there were 2 beds, TV, a chair, exercise equipment, and personal items such as clothing, medications, shoes, etc.

Civil Penalty is being assessed today in the amount of $100 as the facility did not complete the Criminal Background Clearance Transfer Request for staff #1.

LPA requested for a copy of the Liability Insurance to be submitted to CCL on 9/16/2024.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with administrator. A copy of this report and Appeal Rights were provided.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/12/2024 05:37 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMERALD RETIREMENT RESIDENCE	FACILITY NUMBER: 415600003
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

This requirement is not met as evidenced by:87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department,
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed a storage unit in the yard that contained of beds, furniture and personal belongings such as shoes, medication, vitamins, etc. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2024
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure the safety of the facility and in the plan, it shall indicate what is the plan for the storage unit. If the plan is to proceed with making it as a legal ADU, the plan shall indicate the steps that the facility will take to achieve it; if the plan is to remain the unit as a storage unit, the administrator will remove all the livable items in the unit and will provide proof of it. The administrator will provide a copy of the plan to CCL by 9/13/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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