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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600781
Report Date: 11/20/2024
Date Signed: 11/20/2024 04:09:34 PM

Document Has Been Signed on 11/20/2024 04:09 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 HILLS CARE HOMEFACILITY NUMBER:
415600781
ADMINISTRATOR/
DIRECTOR:
COLLINS, MARIA L.FACILITY TYPE:
740
ADDRESS:1871 CORDILLERAS ROADTELEPHONE:
(650) 465-9430
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY: 6CENSUS: 6DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:32 AM
MET WITH:Maria Collins, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On November 20, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:32 AM to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Maria Collins, Administrator and explained the purpose of the visit.

LPA toured the physical plant. This is a 1-story building with 6 bedrooms and three bathrooms, front yard, garage, office, living room, dining room, and backyard. All bedrooms had the required furniture and sufficient lighting. No accessible bodies of water or hazards were observed in hallways or the front and back yards. The facility was kept at a comfortable temperature. The hot water temperature was within the required 105-120 degrees Fahrenheit. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility's first aid kit had the required items.

All sharp objects, soap, detergent, and poisons were observed to be locked and in-accessible to persons in care.

LPA Calandra reviewed 6 resident files and 3 staff files. All files were observed to be complete.

LPA Calandra conducted 3 resident interviews.

A review of Centrally Stored Medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

During the visit, the following documents were collected:
- Current Liability Insurance
- Infection Control Plan
- Current Administrator Certificate

The facility will send the current LIC 500 to the Regional Office (RO) by 11/27/2024.

The deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties.

An exit interview was conducted. This report was reviewed with Maria Collins, Administrator and a copy of the report left at the facility.

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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 11/20/2024 04:09 PM - It Cannot Be Edited


Created By: John Calandra On 11/20/2024 at 02:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(e)(3)(B)
Other Provisions
(e) Each person who provides employee training under this section shall meet the following education and experience requirements: (3) The licensed residential care facility for the elderly shall maintain the following documentation on each person who provides employee training under this section: (B) Information on the topics or subject matter covered in the training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, S1, S2, and S3's employee records did not have have information on the topics or subject matter covered in trainings, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee/Administrator to submit all training documentation to CCLD by the Plan of Correction due date.
Type B
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
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Based on record review, the Licensee has not conducted quarterly emergency drills which need to take into account different emergency scenarios, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee/Administrator to conduct a quarterly emergency drill including all staff from all shifts and send the sign in sheet for this training and all future trainings to Licensing. Licensee/Administrator will also prepare materials that will be reviewed with staff and residents in care.
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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
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