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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600823
Report Date: 06/29/2023
Date Signed: 06/29/2023 02:25:05 PM

Document Has Been Signed on 06/29/2023 02:25 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
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: 3DATE:
06/29/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Isabelle GilTIME COMPLETED:
02:45 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced 1 year annual continuation inspection visit. LPA met with licensee Isabelle Gil and explained the purpose of today's visit.

LPA inspected the facility inside and out including, 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 which are in place. LPA tested the hot water temperature in the kitchen measuring at 110F. Smoke detectors in compliance with fire safety and are functioning according to the licensee. LPA observed the presence of one carbon monoxide detector in dining room area adjacent to carbon monoxide. Passageways and hallways were observed free of obstruction. A review of staff records on 06/29/2023 indicate that all facility staff or individual who require caregiver background checks have received criminal record clearances. All staff are associated as required. Surety bond is on file expiring on 10/17/2023. Liability insurance is on file dated 05/03/2023. Lease agreement on file expiring 12/31/2023. Disaster plan is on file dated 2023. Fire extinguisher in kitchen is fully charged and last inspected on 09/26/2022. Administrator certificate is current expiring 06/29/2024.

At 1:15PM, LPA reviewed a sample of client files including cash resources and medications. Staff files including required and continued training are reviewed as current. Medications are inspected as in place and accounted for.

No deficiencies are cited. Report is reviewed with the licensee on this day.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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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