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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600823
Report Date: 06/23/2023
Date Signed: 06/23/2023 02:12:38 PM

Document Has Been Signed on 06/23/2023 02:12 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:EMERALD RESIDENTIAL CARE HOMEFACILITY NUMBER:
415600823
ADMINISTRATOR:GIL, ISABELLE B.FACILITY TYPE:
740
ADDRESS:1749 NEWBRIDGE AVENUETELEPHONE:
(650) 348-3054
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 4DATE:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Esterlina DumanagTIME COMPLETED:
02:15 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced 1 year annual inspection visit. LPA met with caregiver Esther Dumanag and explained the purpose of today's visit.

LPA toured the facility and it was observed to be clean. Bedrooms are equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable.

Central stored medication, toxins and sharps objects were locked and inaccessible to residents.

1 resident medication file is reviewed. LPA conducted staff interviews.

At 1:55pm administrator arrived to the facility to meet LPA.

LPA could not complete the annual inspection on this day and will return another day to complete this inspection.

No deficiency cited as of today. This report is reviewed and discussed. A copy is provided the the administrator.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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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