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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002781
Report Date: 03/14/2023
Date Signed: 03/14/2023 01:12:49 PM

Document Has Been Signed on 03/14/2023 01:12 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
CCLD Regional Office,
, CA
FACILITY NAME:EMERALD RESIDENTIALFACILITY NUMBER:
455002781
ADMINISTRATOR:CULVER, REBECCAFACILITY TYPE:
735
ADDRESS:1132 GROUSE DRTELEPHONE:
(530) 200-0701
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 6CENSUS: 4DATE:
03/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Billie Bergen - Direct Care StaffTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Inspection Visit utilizing the infection control domain. LPA met direct care staff and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; facility administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by direct care staff.
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LPA and direct care staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. In the areas toured no immediate health, safety, or personal rights violations were observed. There are four private bedrooms, and kitchen, two bathrooms, dining room, living room and staff office.. There is an outdoor activity space with shaded areas. LPA and direct care staff completed the full care tool and facility was found to be in substantial compliance at this time. Surety Bond expires 12/1/2024.

LPA observed hot water temperature was measured at 112.5 degrees Fahrenheit in kitchen sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire Extinguishers were inspected on 6/1/2022 and in compliance. Smoke and carbon monoxide detectors are in compliance with fire safety. LPA observed centrally stored medications locked up in medication rooms. LPA reviewed two (2) resident and two (2) staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete.

No deficiencies are being cited as a result of today's inspection.
Exit interview conducted and copy of report left with direct care staff.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023
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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