486804081-9-11-2023-21-AS-CFOR-CV2QQG-20230825122218

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804081
Report Date: 08/25/2023
Date Signed: 09/11/2023 04:18:16 PM

Document Has Been Signed on 09/11/2023 04:18 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	EMERALD HOME		FACILITY NUMBER:	486804081
ADMINISTRATOR:	BUNYI, LEONILA		FACILITY TYPE:	740
ADDRESS:	305 KEYES CT.		TELEPHONE:	(510) 421-4182
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	5	CENSUS: 2	DATE:	08/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Magdalena Dixon, Caregiver		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 09:15AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a Required 1 Year annual inspection and met with Staff Member, Magdalena Dixon and Jenifer Culili. Facility has an approved fire clearance for 5 non-ambulatory residents total capacity of 5 residents. Facility has an approved hospice waiver for 5 individuals. Administrator, Leonila Bunyi, arrived later during visit at approximately 09:45AM. LPA conducted a tour of the facility and observed the following: the facility was clean and at a comfortable temperature with all exits free from obstruction. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Toxins were secure and not accessible to residents. There is a sufficient supply of hygiene products, paper products, and linens available for resident use. Mattress pads were in place or available for resident use. Medication was centrally stored and secure. LPA reviewed 2 of 2 resident records. During review of resident records, Per facility's license, facility is approved for 5 hospice individuals at a time. LPA reviewed a sample of staff records. LPA reviewed 4 staff files. Staff files were found to be organized with proper documentation. Administrator's Certificate (606020104740) was current with an expiration date of 10/20/2024. Continued on LIC809C.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: EMERALD HOME	FACILITY NUMBER: 486804081
	VISIT DATE: 08/25/2023

NARRATIVE

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Continue from LIC809

LPA and Administrator discussed facility's emergency and evacuation plan. The facility's last fire and evacuation drill will be conducted 08/25/2023. Facility's fire extinguishers were last inspected August 10,2023. Smoke detectors and carbon monoxide detectors were tested and operational. The amount of fresh and non-perishable foods are within regulation. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

LPA conducted staff and resident interviews.

LPA requested the following documents to update facility file:
· Designation of Facility Responsibility (LIC 308)
· Control of Property
· Emergency Disaster Plan (LIC 610D)
· Health Screening Report for Administrator (LIC 503)
· Updated Personnel Report (LIC 500)
· Updated Liability Insurance
· Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Monday 09/04/2023

No deficiencies observed or cited during today's Required 1- Year inspection. Copy of this report provided.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC809 (FAS) - (06/04)

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