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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600780
Report Date: 10/06/2023
Date Signed: 10/06/2023 03:42:42 PM


Document Has Been Signed on 10/06/2023 03:42 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:
10/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee Lailo MatiasTIME COMPLETED:
04:00 PM
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On 10/06/2023 at 1:00 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced for an annual inspection. The LPA stated the purpose of the visit to Caregiver Odette Mendoza upon entering the facility.

During the Inspection, the LPA inspected the facility inside and outside. LPA interviewed 2 staff members and 2 residents, and reviewed the records of 5 staff and 5 residents.

LPA observed that the facility has a sufficient supply of food: 2 days perishable and 7 days nonperishable. A comfortable inside temperature of 73.4 degrees F was maintained. The facility was clean and the staff attentive to residents' needs.

No citations issued.

Exit interview conducted with Licensee and a copy of this report was provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
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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