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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600823
Report Date: 07/27/2019
Date Signed: 07/27/2019 03:17:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:EMERALD RESIDENTIAL CARE HOMEFACILITY NUMBER:
415600823
ADMINISTRATOR:GIL, ISABELLE B.FACILITY TYPE:
740
ADDRESS:1749 NEWBRIDGE AVENUETELEPHONE:
(650) 348-3054
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 6DATE:
07/27/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Ma Ellena CatapalTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Rolanda Pitcher arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Staff, Ma Ellena Catapal for this purpose. The Administrator is Licensee, Isabelle Gil, certificate (6015187740) will expire on 6/29/2020.

LPA inspected the facility inside and out including but not limited to client bedrooms, living room, dining area, kitchen, bathroom, garage and backyard. Both inside and outside of the facility were free of obstruction. Facility is free of odor and was observed to be clean. LPA observed sufficient furniture and lighting throughout the facility. LPA inspected a seven day non-perishable and two day perishable food.

LPA tested the hot water temperature in clients bathroom sink, which is within the required range of 105 to 120 degree F. LPA tested smoke detectors in compliance with fire safety. LPA observed the presence of one carbon monoxide detector in the hallway. Passageways and hallways were observed free of obstruction.

At 2:00PM, LPA reviewed a sample of client files including cash resource and medications and staff files including required and continued training.

A review of staff records on 7/27/2019 indicate that all facility staff or individual who require caregiver background checks have received criminal record clearances.

No deficiencies were cited.

Exit interview was conducted with Ma Ellena Catapal

SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda PitcherTELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2019
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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