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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600780
Report Date: 10/03/2024
Date Signed: 10/03/2024 03:00:50 PM


Document Has Been Signed on 10/03/2024 03:00 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:EMERALD CARE HOMEFACILITY NUMBER:
075600780
ADMINISTRATOR:MATIAS, LAILO A.FACILITY TYPE:
740
ADDRESS:113 ROCK OAK COURTTELEPHONE:
(925) 935-7899
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Licensee Lailo MatiasTIME COMPLETED:
03:15 PM
NARRATIVE
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On 10/3/2024 at 10:45 AM, Licensing Program Analysts (LPA) James Sampair arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPA stated the purpose of the visit to Licensee Lailo Matias.

The LPA inspected the interior and exterior of the facility. The inspection of the physical plant included the kitchen, dining area, restrooms, community living spaces, resident rooms, storage areas, garage, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. At approximately 12:45 PM, temperature of the hot water was 110 degrees in the kitchen and the room temperature in the living room was 75.5 degrees. The fire extinguisher was replaced on 7/8/2024.

The carbon monoxide and smoke detectors were fully operational. The LPA observed required postings in the facility, including the Residential Care Facility for the Elderly Complaint Poster, Ombudsman and Personal Rights posters, and the Theft and Loss Policy. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations.

The LPA reviewed facility records, records of 5 residents, and records of 5 staff members. The LPA interviewed 3 staff members.

1 Type-B citations issued during the inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
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 2


Document Has Been Signed on 10/03/2024 03:00 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: EMERALD CARE HOME
FACILITY NUMBER: 075600780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

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 did not have 72 hours of food and 30 gallons of water for residents and staff designated for emergency use only, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Licensee shall designate for emergency use only 72 hours of food and 30 gallons of water for residents and staff on or before the due date and send proof to LPA.
Section Cited
Other Provisions
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) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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