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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600781
Report Date: 12/17/2020
Date Signed: 01/04/2021 02:00:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:EMERALD HILLS CARE HOMEFACILITY NUMBER:
415600781
ADMINISTRATOR:COLLINS, MARIA L.FACILITY TYPE:
740
ADDRESS:1871 CORDILLERAS ROADTELEPHONE:
(650) 465-9430
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:6CENSUS: 5DATE:
12/17/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Maria CollinsTIME COMPLETED:
04:30 PM
NARRATIVE
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On 12/17/2020 at 0930 Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced tele-inspection. LPA is delivering citations observed on a tele-inspection conducted on 12/15/2020 with LPA Han, LPM Julio Montes, and PCC Roxane Fangon. LPA met with licensee Maria Collins and explained purpose of tele-inspection.

LPA made facility observations during today's tele-inspection in regards to the recommendations made by PCC Fangon. LPA observed the PPE donning station. The CDC instructional poster for donning and doffing were placed in these areas for staff review. LPA observed the revised symptom screening log. It now shows a list of symptoms being screened for with date and signature line. Lastly, LPA observed the the placement of the hand hygiene poster at the kitchen sink and additional bathrooms within facility. Licensee says she is in the process of reviewing the training materials, abiding by the advice given, and reviewing videos regarding the proper sealing of N95 masks and the donning and doffing of PPE.

The following were recommended by PCC to be completed by the facility:
1. Need more training on donning and doffing of PPE

2. Revise the screening log to include all symptoms review questions (currently the facility is only asking the questions and it is not being documented)

3. Ensure proper sealing of N95 mask for licensee and staff per training document being forwarded to licensee

4. Posting of CDC instructional poster regarding donning and doffing of PPE

5. Placement of hand hygiene poster at kitchen sink and all hand washing locations

Continued on next page...
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMERALD HILLS CARE HOME
FACILITY NUMBER: 415600781
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2020
Section Cited

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Administrator Qualifications and Duties - All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
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This requirement has not been met as evidenced by: Licensee did not properly request hospice waiver increases for facility; opted to operate with low staffing when there were no longer any COVID negative residents, failed to obey San Mateo County Department of Public Health COVID guidance regarding staffing for negative and positive COVID residents; and not submitting linelist timely.
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Type A
12/31/2020
Section Cited

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Personal Rights of Residents in All Facilities - Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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This requirement has not been met as evidenced by: Licensee was allowing COVID+ staff, including herself, care for a COVID negative resident which does not accord a safe and healthful environment.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMERALD HILLS CARE HOME
FACILITY NUMBER: 415600781
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2021
Section Cited

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Limitations On Capacity & Ambulatory Status - A licensee shall not operate a facility beyond the conditions and limitations specified on the license.
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This requriement has not been met as evidenced by: Licensee retained more hospice care residents. Facility is approved for 2 and at one point had 4 residents on hospice. Licensee also requested hospice waiver increase incorrectly. This does not meet Department regulations.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: EMERALD HILLS CARE HOME
FACILITY NUMBER: 415600781
VISIT DATE: 12/17/2020
NARRATIVE
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Page 2: Case Management - Other

During the course of the tele-visit conducted on 12/15/2020 and with contacts made with the Department facility was found to have hospice residents beyond waiver approval of 2 hospice residents. At one point facility had 3 to 4 hospice residents. Waiver requests were submitted incorrectly lacking the appropriate information for a waiver increase. Facility also opted to have lower staffing level due to not having any more negative residents in the facility. Licensee was the only staff providing care to those residents. Licensee did not abide by county recommendations in providing care to negative residents with negative staff and submitting line lists in a timely manner to San Mateo Department of Health and the Department for COVID tracking purposes and monitoring

Under California Code of Regulations, Title 22, Division 6, deficiencies are being cited on the attached LIC809D. Report is discussed with the licensee Maria Collins and a copy is provided via email for signature. Appeal rights are provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4