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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600823
Report Date: 03/04/2025
Date Signed: 03/04/2025 11:48:19 AM

Document Has Been Signed on 03/04/2025 11:48 AM - 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:
03/04/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Isabelle Gil, Elnora Panilag, Esterlina DumanagTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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During plan of correction visit, LPA Jeung observed deficiency of the California Code of Regulations, Title 22. Citation appears on a following page.

Information about safeguarding of clients' cash resources is provided to administrator.

In addition, LIC200 is corrected in LPA's presence to accurately reflect requested change from non-ambulatory to one bedridden client.

Licensee is also requested to submit lease addendum--signed and dated by landlord.

Acknowledgement of a correction is issued--1 page.
.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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 03/04/2025 11:48 AM - It Cannot Be Edited


Created By: Audrey Jeung On 03/04/2025 at 11:03 AM
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: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2025
Section Cited
CCR
87468.1(a)(13)

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PERSONAL RIGHTS
Residents in all RCFEs shall have the right... to have access to individual storage space for private use. This requirement is not met, as personal belongings of staff--clothing, suitcases, purse, plastic bags--are stored in room of client #4, adjacent to dining room.
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Personal items of staff were removed from room #5 in LPA's presence.
Deficiency corrected and cleared
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Licensee failed to ensure that clients have their own personal storage space, which poses an immediate 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: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
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