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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600823
Report Date: 02/25/2025
Date Signed: 02/25/2025 06:16:31 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/25/2025 06:16 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 HOMEFACILITY NUMBER:
415600823
ADMINISTRATOR/
DIRECTOR:		GIL, ISABELLE B.FACILITY TYPE:
740
ADDRESS:1749 NEWBRIDGE AVENUETELEPHONE:
(650) 348-3054
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 6DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Esterlina Dumanag, Elnora Panilag, Flory WalinsundinTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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 LPA Audrey Jeung toured facility and grounds, consisting of 6 private client bedrooms--2 of which have exit doors to outside, and 3 of which have private full bathrooms. There is a common bathroom, living room, dining room, and kitchen. Backyard is level and fenced, and there is a detached storage shed. There are 3 staff present. A comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hot water temperature is tested.
Food supply and first-aid kit are inspected. All client files are reviewed. Centrally Stored Medications Records and clients' cash handling records will be reviewed at a later date. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as other staff records. Isabelle Gil is a certified RCFE administrator (x 6/26) that oversees facility operations.
Due to time constraints, this report is incomplete. Deficiencies observed will be cited at a later date.

The following forms/information are requested to be completed and returned to CCL by 3/11/25:

• LIC 309 Administrative Organization
• LIC 400 Affidavit regarding Client Cash Resources
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610D Emergency Disaster Plan (signed and dated)
• LIC 9282 Infection Control Plan
- Proof of control of property (signed and dated lease)
- Proof of current liability insurance
- Annual license renewal fee of $1237 is due and payable.



Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on page THREE.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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 02/25/2025 06:16 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/25/2025 at 05:13 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 RESIDENTIAL CARE HOME
FACILITY NUMBER: 415600823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2025
Section Cited
CCR
87303(e)(2)

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MAINTENANCE AND OPERATION
Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F .
This requirement is not met, as hot water
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Hot water temperature to be lowered and maintained between 105 and 120 degrees. Proof of correction to be sent to CCLD BY DUE DATE
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temperature tested at 132 degrees in common bathroom, which poses an immediate health and safety risk to clients in care.
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Type A
02/26/2025
Section Cited
CCR87468.1(a)(1)

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PERSONAL RIGHTS
Residents in all RCFEs shall have ...the right...to be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met, as there are video baby monitors in 3 clients' rooms, so
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Video baby monitors will be removed and not used. Proof of correction to be sent to CCLD BY DUE DATE.
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staff can monitor clients from the kitchen. This poses an immediate personal rights risk to clients in care. Cameras are placed in rooms of clients #1, #3, #4, and provide video and audio surveillance.
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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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


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Document Has Been Signed on 02/25/2025 06:16 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/25/2025 at 05:32 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 RESIDENTIAL CARE HOME
FACILITY NUMBER: 415600823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2025
Section Cited
CCR
87355(e)(2)

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CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to H & S Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility, request a transfer of a criminal record clearance as specified in Section 87355(c).
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Criminal record clearances for Staff 1, 2, 3, 4, 7 must be associated/transferred to this facility.
Proof of correction to be submitted to CCLD BY DUE DATE to avoid additional penalty assessments.
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This requirement is not met, as 5 staff out of 7 staff files reviewed DO NOT have criminal record clearance associated to this facility. This poses an immediate health, safety or personal rights risk to clients, and civil penalty is assessed at $100/each. Three staff have been employed for over 7 months.
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Type A
02/25/2025
Section Cited
CCR87309(a)

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STORAGE SPACE
The licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked
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Comet cleanser was removed from client's bathroom in LPA's presence.
Deficiency corrected and cleared.
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storage. This requirement was not met, as Comet cleanser stored in bathroom cabinet in private bathroom of client #1, which posed an immediate health, safety or personal rights risk to clients in care.
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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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


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Document Has Been Signed on 02/25/2025 06:16 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/25/2025 at 05:45 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 RESIDENTIAL CARE HOME
FACILITY NUMBER: 415600823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2025
Section Cited
CCR
87202(a)(2)

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FIRE CLEARANCE
All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services.... Prior to accepting or retaining ...bedridden persons, the licensee shall notify the licensing agency &
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Plan/proof of correction to be sent to CCLD BY DUE DATE.
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obtain an appropriate fire clearance approved by the city, county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met, as client #4 is bedridden, but there is no approved fire clearance for bedridden, which poses an immediate health and safety risk.
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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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


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Document Has Been Signed on 02/25/2025 06:16 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/25/2025 at 05:51 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 RESIDENTIAL CARE HOME
FACILITY NUMBER: 415600823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2025
Section Cited
CCR
87465(a)(8)

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INCIDENTAL MEDICAL CARE
A complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least... specific items. This requirement was not met, as first aid kit only
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First aid kit will be maintained and include required items. Proof of correction will be sent to CCLD BY DUE DATE.
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contains Medihoney, several bandaids, a flex fabric, cold pack, and tweezers. Licensee failed to ensure that first aid kit is complete, which poses a potential health, safety or personal rights risk to clients in care.
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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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


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