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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600823
Report Date: 02/25/2026
Date Signed: 02/25/2026 05:03:56 PM

Document Has Been Signed on 02/25/2026 05:03 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: 5DATE:
02/25/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Nora Panilag, Kristine TanTIME VISIT/
INSPECTION COMPLETED:
05:15 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 and 4 clients 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 at 115 degrees in common bathroom. Washer and dryer are located in detached 2-car garage. Food supply and first-aid kit are inspected. All client files are reviewed, including Centrally Stored Medications Records and clients' cash handling records. 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, as well as assistant administrators Michelle Carino-Becerra (x 5/26) and Kristine Tan (x 12/27)

The following forms/information are requested to be completed and returned to CCL by 3/11/26:
• LIC 400 Affidavit regarding Client Cash Resources
• LIC 308 Designation of Administrative Responsibility

Updated Personnel Report (LIC500), proof of current liability insurance and surety bonding are given to LPA.
Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. See also Technical Advisory Notes--3 pages.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 02/25/2026 05:03 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/25/2026 at 03:25 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: 02/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), 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 storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as Ajax cleanser is stored in common bathroom, Comet cleanser stored in bathroom of client #1, and Comet cleanser and liquid Fabuloso stored in bathroom of client #4, accessible to clients, who are present. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2026
Plan of Correction
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Cleansers were relocated to locked storage cabinet in LPA's presence.
Deficiency corrected and cleared.
Type A
Section Cited
CCR
87355(e)(4)
Criminal Record Clearance
(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: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff record review, the licensee did not comply with the section cited above in 1 out of 5 staff files reviewed, which poses an immediate health, safety or personal rights risk to persons in care.
- Criminal record clearance for Staff #3 is not associated to this facility, and needs to be transferred.
POC Due Date: 02/26/2026
Plan of Correction
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Criminal record clearance of staff #3 will be transferred to this facility and proof of correction to be sent to CCLD BY DUE DATE.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2026 05:03 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/25/2026 at 03:25 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: 02/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during facility tour, the licensee did not comply with the section cited above, as Albuterol and Claritin are stored in dresser in room of client #1, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2026
Plan of Correction
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Claritin and Albuterol were removed from room of client #1 and stored in locked medications cabinet.
Deficiency corrected and cleared.
Type A
Section Cited
CCR
87468.2(a)(1)
PERSONAL RIGHTS
In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have ...personal rights...to have a reasonable level of personal privacy in accommodations,

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as 2 staff are observed preparing to eat lunch in bedroom of client #2, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2026
Plan of Correction
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Bedrooms of clients shall not be used by staff for personal use. Plan of correction to be sent to CCLD BY DUE DATE.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2026 05:03 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/25/2026 at 03:25 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: 02/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as wooden hand rail outside of kitchen exit to driveway is broken, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2026
Plan of Correction
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Wooden hand railing will be repaired or replaced, and proof of correction to be sent to CCLD BY DUE DATE
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2026 05:03 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/25/2026 at 03:25 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: 02/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff record review, the licensee did not comply with the section cited above in 3 out of 5 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- Health screenings are not maintained for staff #2, #3, #5, and TB test result is needed for staff #3, who was employed in 2020.

POC Due Date: 03/11/2026
Plan of Correction
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Health screenings and/or TB test results for Staff #2, #3, #5 will be sent to CCLD BY DUE DATE.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2026 05:03 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/25/2026 at 03:25 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: 02/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on staff record review, the licensee did not comply with the section cited above in 2 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There is no evidence of required training for staff #2 and #5, who started working in August 2025.
POC Due Date: 03/11/2026
Plan of Correction
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Staff #2 and #5 will received required 40 hours of training, and proof of correction to be sent to CCLD BY DUE DATE.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 02/25/2026 05:03 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/25/2026 at 03:25 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: 02/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff record review, the licensee did not comply with the section cited above in 1 out of 5 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There is no evidence that Staff #3 has received annual training, including 8 hours of dementia training and 4 hours of training restricted health conditions, postural supports and hospice care.
POC Due Date: 03/11/2026
Plan of Correction
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2
3
4
Proof that staff #3 received required annual training will be sent to CCLD BY DUE DATE
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff record review, the licensee did not comply with the section cited above in 3 out of 3 medications staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- Medications staff #6, #7, #8 have not had annual medication training. Last training was in 2024.
POC Due Date: 03/11/2026
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2026 05:03 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/25/2026 at 03:25 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: 02/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.319(a)
Regulations
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as there is no internet capable device for client use only, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2026
Plan of Correction
1
2
3
4
An internet capable device for client use only will be maintained and available for clients. Proof of correction to be sent to CCLD BY DUE DATE
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on client records review, the licensee did not comply with the section cited above in 2 out of 5 client files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
Medical assessments for clients #3 and #5 are not signed and identified by a physician.
POC Due Date: 03/11/2026
Plan of Correction
1
2
3
4
MD reports for clients #3 and #5 signed by physicians will be sent to CCLD by DUE DATE
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2026


LIC809 (FAS) - (06/04)
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