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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002765
Report Date: 09/08/2020
Date Signed: 09/08/2020 12:42:00 PM

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 OAKSFACILITY NUMBER:
515002765
ADMINISTRATOR:BAKER, BECKYFACILITY TYPE:
740
ADDRESS:2290 FORREST LANETELEPHONE:
(530) 751-0511
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY:116CENSUS: 57DATE:
09/08/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Becky Baker; AdministratorTIME COMPLETED:
01:00 PM
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On 9/8/2020 at 10 AM, Licensing Program Analyst (LPA) Cheng conducted an announced prelicensing visit via video chat and met with Administrator Becky Baker. A video inspection was conducted per the departments procedures regarding COVID-19. LPA explained reason for visit and toured the visit inside and out including but not limited to facility recreation area, dining area, kitchen area, outside area, hallways, laundry rooms, medication rooms, and resident rooms. Facility has 7-day non-perishable and 2-day perishable supply of food along with an emergency food supply. Hot water temperature measured at 106 degrees Fahrenheit. All rooms are fully furnished and outside areas are free of obstruction and bodies of water. Facility has an alarm and delayed egress system for their Dementia residents. Medications are centrally stored in a locked room that is only accessible by key.

Smoke, carbon monoxide, and fire alarm systems were observed as operational. Fire extinguishers were observed as full. First aid kit was observed as complete.

LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted. Two copies of the report was given and LPA requested for a signed copy to be returned.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020
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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