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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600003
Report Date: 10/14/2026
Date Signed: 10/14/2026 02:20:40 PM

Document Has Been Signed on 10/14/2026 02:20 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:EMERALD RETIREMENT RESIDENCEFACILITY NUMBER:
415600003
ADMINISTRATOR/
DIRECTOR:		ISABELLE GILFACILITY TYPE:
740
ADDRESS:717 WIDGEON COURTTELEPHONE:
(650) 358-8868
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 6CENSUS: 6DATE:
10/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Assistant Administrator, Kristine TanTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On October 14, 2026, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by Assistant Administrator, Kristine Tan and LPA explained the purpose of today's visit.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables, Facility has 5 resident bedrooms (4 private rooms and 1 shared room), 1 staff room, 2 full- bathrooms, kitchen, and common areas. The facility observed to clean, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Hot water temperature was measured at 106-116 degrees F.

During the tour of the facility, LPA observed a storage unit/shed in the backyard with furniture such as a coffee table, and a couch and personal items such as clothes, luggage, shoes, shoe racks, water, laundry basket with clothes inside, and staff #2 (S2) was sitting on the couch. According to the assistant administrator, staff utilized this space for breaks.

The emergency drills were reviewed to be complete.



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

Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
April Cowan
Murial Han
DATE: 10/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2026
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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Document Has Been Signed on 10/14/2026 02:20 PM - It Cannot Be Edited


Created By: Murial Han On 10/14/2026 at 01:33 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMERALD RETIREMENT RESIDENCE
FACILITY NUMBER: 415600003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)
Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as During the tour of the facility, LPA observed a storage unit/shed in the backyard that consisted furniture such as a coffee able, and a couch and personal items such as clothes, luggage, shoes, shoe racks, water, clothes, laundry basket with clothes inside, and staff #1 was sitting on the couch during the tour. According to the assistant administrator, staff utilized this space for staff breaks. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2026
Plan of Correction
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The administrator/licensee will develop a plan to ensure staff members not taking their breaks in the storage unit/shed as the storage unit is for storage purposes. The plan of correction shall also indicate a comfortable living accommodation for staff to take their breaks. The administrator/licensee will submit a copy of the plan of correction to CCL by 10/14/2026.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed S3 who was hired in Nov 2024 did not have a health screen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2026
Plan of Correction
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The administrator/licensee will develop a plan to ensure all staff members have a completed health screen upon hire. The administrator / licensee will provide a copy of the plan of correction and a copy of S3's health screen to CCL by 10/21/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2026


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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: EMERALD RETIREMENT RESIDENCE
FACILITY NUMBER: 415600003
VISIT DATE: 10/14/2026
NARRATIVE
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A review of (5) resident files was conducted and noted on the LIC 858.
A review of (4) staff files was conducted and noted on the LIC 859.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with asst. administrator. A copy of this report and Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2026
LIC809 (FAS) - (06/04)
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