415600823-2-21-2024-14-AS-JVAO-D2NVM9-20240221153310

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600823
Report Date: 02/21/2024
Date Signed: 02/21/2024 03:33:21 PM

Document Has Been Signed on 02/21/2024 03:33 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 RESIDENTIAL CARE HOME		FACILITY NUMBER:	415600823
ADMINISTRATOR:	GIL, ISABELLE B.		FACILITY TYPE:	740
ADDRESS:	1749 NEWBRIDGE AVENUE		TELEPHONE:	(650) 348-3054
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	6	CENSUS: 5	DATE:	02/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Caregiver - Elnora Panilag		TIME COMPLETED:	03:45 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 02/21/2024 Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced 1 year annual inspection visit. LPA met with caregiver Elnora Panilag and explained the purpose of today's visit. LPA toured the facility inside and outside. Emergency exit routes are free and clear of obstructions. The facility's ambient temperature is comfortable and warm. Water is tested in two communal bathrooms as being 120F. Residents have an adequate amount of linens and incontinence supplies, incidental supplies, as well as PPE as needed. One fire extinguisher is observed in the kitchen. Upon observation of the charge on the dial display it is within the green zone indicating it is charged and ready for use. The inspection tag indicates it was last inspected on 09/25/2022. Facility is equipped with fire sprinklers. Carbon monoxide detectors and smoke detectors are present through out the facility. Two resident bathrooms were observed to be in good repair. Client bathrooms are observed to be in working order with clean shower curtains and non-skid surfacing and strips are in place. 7 day non-perishable food supply and 2 day fresh food supply is observed as in place. Kitchen is observed as operable and clean. Appliances are in good working order. LPA observed that the knives for cooking is locked in a small cabinet next to the stove. Medications are also observed as locked in a stand up cabinet in the kitchen. Medications are inaccessible to residents. Medication administration record is observed as current. First aid kit is observed with the medications as complete. 2 resident files are reviewed as being current. Continue on next page...

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMERALD RESIDENTIAL CARE HOME	FACILITY NUMBER: 415600823
	VISIT DATE: 02/21/2024

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Page 2 - LIC809C

On site laundry is available and functioning per observations made in the garage. Cleaning supplies are observed as locked in garage and in storage cabinets in the garage. An additional refrigerator is located in the garage that contains additional resident food as well as staff's personal food items.

2 client records are checked and both are complete and updated. At time of inspection, there is only one resident who has money being stored for safekeeping by staff. This is inspected and is observed as current. 3 Staff files are reviewed as current. At time of inspection. There is one staff (S1) not associated to the facility and no fingerprint clearance on record with the Department.

The following updated items are requested to be sent to the Department by 02/28/2024:

• LIC610D Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance
• Proof of control of property
• Surety bond with expiration date

Citations issued on following LIC809D.

Civil penalty assessed for staff person with no finger print clearance on file with the Department and not being associated to the facility. S1 x (2 violations) at $100 = $200

Report is reviewed with caregiver Elnora Panilag.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/21/2024 03:33 PM - 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMERALD RESIDENTIAL CARE HOME	FACILITY NUMBER: 415600823
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/22/2024 Section Cited CCR 87355(e)(2)	1 2 3 4 5 6 7	All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator shall ensure to submit a criminal record clearance transfer request to the licensing office for S1 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
	8 9 10 11 12 13 14	Based on records review, licensee failed to request a transfer of criminal record clearance for S1 and S2 which poses an immediate health and safety risk to clients in care. It is confirmed that S1 and S2 are not associated to the facility on this day 7/1/2022.	8 9 10 11 12 13 14	Immediate civil penalty of $100 for S1 and is being assessed on this day.
Type A 02/22/2024 Section Cited CCR87355(e)(1)	1 2 3 4 5 6 7	(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator shall ensure to submit a criminal record clearance transfer request to the licensing office for S1 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
	8 9 10 11 12 13 14	Based on records review, licensee failed to obtain a criminal record clearance for S1 which poses an immediate health and safety risk to clients in care. It is confirmed that S1 does not have a criminal record clearance on this day.	8 9 10 11 12 13 14	Immediate civil penalty of $100 for S1 and is being assessed on this day.

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: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC809 (FAS) - (06/04)

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