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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002781
Report Date: 03/26/2024
Date Signed: 03/26/2024 11:28:04 AM

Document Has Been Signed on 03/26/2024 11:28 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
03/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Adminstrator Chantelle BrowningTIME COMPLETED:
11:40 AM
NARRATIVE
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On 03/26/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Chantelle Browning and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, backyard, shed, and common restrooms.

LPA observed each bathroom to have the necessary grab bars, paper towels, trash can with lids and 20-second hand-washing poster. LPA observed the bathroom to be in need of repair, the outside of the bathtub and the wall near the tub appear to have mold and are in need of repair. LPA observed the residents bedrooms to have all the required furnishings, windows with screens and working lights.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured within the required range. LPA observed the dishwasher and freezer to be in need of repair which was leaking water. LPA observed chemical toxins to be stored under the kitchen sink accessible to the residents.

LPA observed two (2) fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed the first aid kit to be complete and ready for use. LPA was unable to review the emergency disaster plan as it was incomplete, and there were no emergency disaster drills conducted in the last 12 months.

LPA reviewed a total of four (4) residents' files and two (2) staff files which contained all of the required documentation.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.



An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
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 3
Document Has Been Signed on 03/26/2024 11:28 AM - It Cannot Be Edited


Created By: Jaynae Boyles On 03/26/2024 at 10:59 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EMERALD RESIDENTIAL
FACILITY NUMBER: 455002781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, 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 in that the freezer, dishwaster and bathroom floor are in need of repair, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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Admin will create a plan to ensure that these items are repaired and inform the LPA via email. Admin will keep the LPA informed regarding the progress to repair these items.
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 in that several chemical toxins were stored under the kitchen sink accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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Admin will ensure that all staff are trained on the importance of storing chemical toxins inaccessable to residents. Admin will infom the LPA of this training via email. Admin will ensure that all chemical toxins are stored inaccessable to residents.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/26/2024 11:28 AM - It Cannot Be Edited


Created By: Jaynae Boyles On 03/26/2024 at 10:59 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EMERALD RESIDENTIAL
FACILITY NUMBER: 455002781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that the emergency disaster plan is not complete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Admin will complete the emergency disaster plan and ensure that all staff are aware of the plan. Admin will inform LPA that this form is complete and is reviewed annually.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that no emergency disaster drills were conducted in the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Admin will develop a plan to ensure that emergency disaster drills are conducted as required and share that plan with the LPA.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024


LIC809 (FAS) - (06/04)
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