415600003-10-20-2023-14-AS-MHAN-CWRQBF-20231019120128

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600003
Report Date: 10/19/2023
Date Signed: 10/20/2023 11:17:26 AM

Document Has Been Signed on 10/20/2023 11:17 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
SF COASTAL AC/SC, 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: 6	DATE:	10/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Caregiver, Luisa Dizon		TIME COMPLETED:	12:10 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 October 19, 2023 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregivers, Luisa Dizon and Maria Burgos and LPA explained the purpose of today's 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- 112 degrees F. The most recent emergency drill was conducted on June 24, 2023. Fire extinguisher(s), smoke and carbon monoxide detectors in the facility. Central stored medication, toxins and sharps objects were locked and inaccessible to residents. Staff training records were reviewed to be adequate. LPA reviewed 6 resident files and all of them contained medical assessment, and GGRC/IPP. However, 3 out of 3 resident's file did not contain a facility Admission Agreement, and 4 out of 6 residents did not have an Appraisal Needs and Service Plan. This observation was presented to the caregivers. LPA reviewed 3 staff files that contained personnel records, health screening, Job Description, Abuse Statement, First Aide and CPR, Criminal Record Statement.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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 11:17 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMERALD RETIREMENT RESIDENCE	FACILITY NUMBER: 415600003
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review the licensee did not comply with the section cited above as 4 out of 6 residents did not have a service needs and plan in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/26/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee will develop a plan to ensure compliance and will provide a copy of the completed service needs and plan to CCL by the plan of correction due date 10/26/2023.

Type B

Section Cited

CCR

87507(d)

Admisson Agreements

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review the licensee did not comply with the section cited above as 3 out of 6 residents did not have a copy of the facility admission agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/26/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee will develop a plan to ensure compliance and will provide a copy of the completed admission agreement for the 3 resident to CCL by 10/26/2023.

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMERALD RETIREMENT RESIDENCE	FACILITY NUMBER: 415600003
	VISIT DATE: 10/19/2023

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During today's inspection, there are 4 residents present and 2 were attending the adult day program.

LPA requested for a copy of the Liability Insurance, and Control of Property to be submitted to CCL by 10/20/2023

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 caregivers. A copy of this report and Appeal Rights were provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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