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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600729
Report Date: 06/01/2023
Date Signed: 06/01/2023 12:15:40 PM


Document Has Been Signed on 06/01/2023 12:15 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:EMERALD CARE HOME IIFACILITY NUMBER:
075600729
ADMINISTRATOR:MATIAS, LAILO A.FACILITY TYPE:
740
ADDRESS:1171 KASKI LANETELEPHONE:
(925) 685-2257
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 6DATE:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Lailo Matias, Administrator TIME COMPLETED:
12:30 PM
NARRATIVE
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On 06/01/2023 at 08:52 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Administrator Lailo Matias and explained the purpose of the visit.

LPA inspected the facility inside out. There is no body of water. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 05/04/2023.

At 9:32 am LPA reviewed 6 residents records. At 10:25 am, LPA reviewed 5 staff records and 5 of 5 were fingerprint cleared and associated to the facility.

The following deficiency was observed during the visit:
The facility does not have an updated floor plan that includes the staff break area or the shed in the backyard

The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided. Exit interview conducted.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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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Document Has Been Signed on 06/01/2023 12:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: EMERALD CARE HOME II
FACILITY NUMBER: 075600729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(7)(b)


This requirement is not met as evidenced by:Each facility shall have and maintain a current, written definitive plan of operation…The plan and related materials shall contain the following: (7) Sketches, showing dimensions, of the following: … (B) The grounds showing buildings, driveways, fences, storage areas, pools, gardens, recreation area and other space used by the residents.
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having the shed in the backyard or the staff break room in the garage as part of the floor plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2023
Plan of Correction
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The Facility will send in an updated floor plan including shed in the backyard or the staff break room in the garage. Proof of correction will be sent to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
LIC809 (FAS) - (06/04)
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