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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804081
Report Date: 07/26/2022
Date Signed: 07/26/2022 02:39:24 PM

Document Has Been Signed on 07/26/2022 02:39 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:EMERALD HOMEFACILITY NUMBER:
486804081
ADMINISTRATOR:BUNYI, LEONILAFACILITY TYPE:
740
ADDRESS:305 KEYES CT.TELEPHONE:
(510) 421-4182
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 5CENSUS: 0DATE:
07/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Leonila Bunyi, applicantTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Katrina Walters conducted a pre-licensing inspection on 07/26/2022. LPA met with Applicants, Leonila Bunyi and Cynthia Dinglasan. Leonila Bunyi will be Administrator when the facility is approved for licensure. On 5/27/22 The facility was granted a fire clearance approval from the Suisun City Fire Department for a capacity of 5 non-ambulatory residents, with no bedridden residents. The facility is one level with 4 bedrooms that may be used for residents, 2 bathrooms, living room, dining room, kitchen, family room, medication cabinet, laundry room with shed and garage. The applicant has a dementia care plan that has been approved.

During today’s visit LPA observed the following: The facility was clean and comfortable temperature. Upon entry there was an area in which staff will check in visitors with hand sanitizer and a temperature gun. LPA observed the following signs posted throughout the facility: Residents right's to counsel, Rights of Individuals with developmental disabilities, Let Us Know complaint poster, hand washing, masks required, personal rights and emergency disaster LIC 610. The Applicant will order the Ombudsman poster and will receive the poster after licensure.

Continued on 809 C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: EMERALD HOME
FACILITY NUMBER: 486804081
VISIT DATE: 07/26/2022
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LPA toured the facility with applicants and found that the facility was clean and a comfortable temperature. All resident's rooms were furnished as required by regulation. A location has been designated for medication and sharps to be locked, and stored. Auditory alarms were on. Bathrooms were equipped with paper towels and hand soap. Grab bars and slip mats were present for residents safety. There was a supply of linens, paper products, and hygiene supplies available. There was at least a 30 day supply of personal protective equipment (PPE). Kitchen was spacious and clean, adequate supply of dishes and utensils. There were non-perishable foods. The facility has a phone line designated for residents use.

Facility has lighting in hallways. LPA confirmed that contents of the facility First Aid Kit were sufficient and that facility has emergency lighting in case of a power outage. Facility has a emergency supply of bottled water. Fire extinguisher was charged and current. Smoke detectors and carbon monoxide detectors were present they were last tested by the fire department on 5/27/22. Exits were observed to be unobstructed. The hot water temperature measured at 118 & 119, in faucets used by residents, which is within regulation.

LPA observed that there was sufficient equipment and supplies to meet the requirements of the activity program including access to reading materials, bingo, painting and other activities. The backyard had a shaded area for visiting and activities.

Applicant will provide LPA with a copy of the liability insurance. LPA conducted a COMP III with applicants some of the following items were discussed: Administrator Qualifications, Reporting Requirements, Maintenance and Operation, Personal Accommodations, Criminal Background clearance, Acceptance and Retention, Restricted and Prohibited Health Care Conditions.

This pre-licensing is complete. LPA will submit the pre-licensing reports to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status. A copy of the report was given to the Applicant.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC809 (FAS) - (06/04)
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