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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200392
Report Date: 10/29/2025
Date Signed: 10/29/2025 03:07:50 PM

Document Has Been Signed on 10/29/2025 03:07 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:EMA BOARD AND CAREHOMEFACILITY NUMBER:
079200392
ADMINISTRATOR/
DIRECTOR:		EDWIN LIWANAGFACILITY TYPE:
740
ADDRESS:1131 ALAMO WAYTELEPHONE:
(925) 458-7098
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 10CENSUS: 5DATE:
10/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Merla Fernandez, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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On 10/29/2025 at 12:00pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Merla Fernandez, Caregiver. LPA spoke with Administrator, Edwin Liwanag, via telephone and explained the purpose of the visit. The administrator holds a certificate #7006273740 expires 10/23/2026. The facility’s fire clearance was approved for eight (8) non-ambulatory and two (2) bedridden residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of seven (7) bedrooms and three (3) bathrooms. One (1) bedroom is occupied by staff. No bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 117.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.

Fire extinguisher was last serviced on 11/05/2024. First aid kit was observed to be complete. Fire drill was last conducted on 10/3/2023.

Continued on LIC809.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392
VISIT DATE: 10/29/2025
NARRATIVE
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Continued from LIC809.

LPA reviewed three (3) staff and observed three (3) of four (4) files were current and complete. All five (5) resident files were reviewed and complete.

LPA requested the following documents to be submitted to CCLD by 11/5/2025.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan (last page)
  • Liability Insurance


LPA observed the following deficiencies:
  • At 12:15, LPA observed during record review R1, R2, R3, and R5, did not have an updated medical assessment and appraisal needs and services plan.
  • At 12:56pm, LPA observed facility did not have a supply of 7-day perishables and 2-day non-perishables foods for residents.
  • At 12:57pm, LPA observed a recliner, 2 wheelchairs, chest of drawers, and 2 bedrails on left hand side of house in back yard.
  • At 1:05pm, LPA observed smoke detectors and carbon monoxide alarms were not operable.
  • At 2:05pm, LPA observed during record review S2 and S3 do not having annual training.
  • At 2:05pm, LPA observed during record reviews S2 and S3 is not first aid or CPR certified.


Continued on LIC809C.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392
VISIT DATE: 10/29/2025
NARRATIVE
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Continued from LIC809C.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2025 03:07 PM - It Cannot Be Edited


Created By: Laura Hall On 10/29/2025 at 02:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in S2 and S3 not being first aid or CPR certified which poses a potential health and safety risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
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Administrator agreed to have S2 and S3 become first aid and CPR certified and submit certification to CCLD by POC date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation and record review, the licensee did not comply with the section cited above in having staff conduct annual training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
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Administrator agreed to have staff conduct annual training and submit certifications and/or in-service sign-in sheets to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2025 03:07 PM - It Cannot Be Edited


Created By: Laura Hall On 10/29/2025 at 02:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having an updated appraisal needs and services plan for R1, R2, R3 and R5 which poses a potential health or safety risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
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Administrator agreed to prepare an appraisal needs and services plan for each resident and submit plans to CCLD by POC date.
Type B
Section Cited
CCR
87555(b)(26)
(b) The following food service requirements shall apply:

(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

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 not having a supply of 7-day non perishables and 2-day perishable for residents which poses a potential health risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
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Administrator agreed to purchase food and submit pictures and receipts to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2025 03:07 PM - It Cannot Be Edited


Created By: Laura Hall On 10/29/2025 at 02:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in having smoke detectors and carbon monoxide detectors operable which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2025
Plan of Correction
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Administrator agreed to replace smoke and carbon monoxide detectors and submit photos to CCLD by POC date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2025 03:07 PM - It Cannot Be Edited


Created By: Laura Hall On 10/29/2025 at 02:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
(d) The following space and safety provisions shall apply to all facilities:

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 having a chest of drawers, 2 wheelchairs, 2 bedrails, a recliner and a chair in passageway which poses a potential safety risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
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Administrator agreed to remove all items and submit photo to CCLD by POC date.
Type B
Section Cited
CCR
87458(b)
(b) The licensee shall obtain an updated medical assessment when required by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having an updated medical assessment for R1, R2, R3, and R5 which poses a potential health or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
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2
3
4
Administrator agreed to have each of the residents and updated medical exam or date for exam and submit copy to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
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