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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804081
Report Date: 11/04/2022
Date Signed: 11/04/2022 03:50:20 PM

Document Has Been Signed on 11/04/2022 03:50 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:
11/04/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Leonila BunyiTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Walters arrived for the purpose of a Post-Licensing inspection. When LPA arrived there were no staff or clients at the present. LPA contacted Leonila Bunyi, Administrator (6020104740 exp 10/20/2022) and Cynthia Dinglasan, Licensee who met LPA at the facility and granted LPA entrance. The facility currently does not have clients in care. Per Administrator they submitted an application to recertify as an Administrator, however they have not received their updated certification. LPA was able to verify through the Administrator bureau that their application was pending.

During today’s visit LPA observed the following items:
· COVID-19 screening station with visitor log, thermometer, hand sanitizer
· Lockable separate cabinets for medications, toxins/cleaners, and knives.
· All exits were unobstructed
· Smoke detectors and carbon monoxide detectors, which were tested & observed operational
· Hand washing and supply of paper products available
· Grab bars, ramps in the bathroom and non-slip mat in shower.
· Auditory devices were observed
· Fire Extinguisher charged 2/22/22
· Required postings (Personal Rights, Emergency plan/numbers, CCLD "Let Us Know" complaint poster, Emergency Disaster Plan, Rights of Individuals with disabilities and COVID-19 signs

No deficiencies cited during today's inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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