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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600431
Report Date: 10/16/2024
Date Signed: 10/16/2024 01:41:26 PM

Document Has Been Signed on 10/16/2024 01:41 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:EMERALD GUEST HOMEFACILITY NUMBER:
374600431
ADMINISTRATOR/
DIRECTOR:		PETRONILA ECHEVARRIAFACILITY TYPE:
740
ADDRESS:2558 MOBLEY STREETTELEPHONE:
(858) 430-6093
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY: 3CENSUS: 3DATE:
10/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Licensee Petronila EschevarriaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Juliana Barfield and Licensing Program Manager (LPM) Lizzette Tellezconducted an unannounced Case Management visit. LPA and LPM introduced themselves and were granted entry into the facility by Licensee's friend, Maria Cisneros. Licensee Petronila Echevarria was contacted by phone and arrived during the visit. LPA and LPM disclosed the purpose of the visit.

During today's visit, LPA and Echevarria discussed a letter of notification received in the San Diego CCL regional office on 10/01/24 that said she was closing her facility. Echevarria said today she would like to remain open and she provided a letter that rescinded the notification of closure of the facility.

LPM and LPA observed that Licensee allowed Person #1 (P1) to be present in the facility without a criminal background record clearance for one (1) day, without supervision. P1 was alone in the facility while Resident #1 (R1) was present with no other staff to provide supervision.

On 8/14/24, the Department conducted an unrelated visit and issued a citation for a violation regarding criminal background clearance. During today's visit, a repeat violation was thus cited per California Code of Regulations, Title 22. An immediate civil penalty of $250 was assessed for a Criminal Record Clearance violation.

An exit interview was done with Licensee Petronila Echevarria to whom a copy of this report, the LIC 809-D, the LIC421, LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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 10/16/2024 01:41 PM - It Cannot Be Edited


Created By: Juliana Barfield On 10/16/2024 at 12:41 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: EMERALD GUEST HOME
FACILITY NUMBER: 374600431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2024
Section Cited
CCR
87355(e)(1)

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CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility obtain a California clearance or a criminal record exemption as required by the Department.
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Licensee arrived after being contacted by phone and P1 left the facility. IMMEDIATE RISK REMOVED.
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This requirement was not met as evidenced by: Based on interview and observation, the licensee did not comply with the section cited above which poses an immediate health and safety risk to R1.
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A civil penalty for a repeat violation in the amount of $250 was issued during today's visit.

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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:Lizzette Tellez
LICENSING EVALUATOR NAME:Juliana Barfield
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
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