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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201753
Report Date: 12/09/2021
Date Signed: 12/10/2021 09:42:08 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:EMERALD ISLE ASSISTED LIVING #2FACILITY NUMBER:
198201753
ADMINISTRATOR:MARTZ, LAURA DAWNFACILITY TYPE:
740
ADDRESS:28016 CALZADA DR.TELEPHONE:
(310) 351-7075
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90274
CAPACITY:6CENSUS: 5DATE:
12/09/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:51 PM
MET WITH:Laura MartzTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced Case Management visit. Upon arrival at the facility, LPA Montoya called the Administrator, Laura Martz and left a voicemail message. Soon later, Martz arrived the facility and assisted LPA Montoya with the visit. LPA Montoya explained the purpose of this visit is to provide technical assistance on Covid-19 protocols due to unavailability of the administrator to assist the department via zoom visit. Martz explained she is busy assisting her four facilities today but she will cancel her errands and will assist LPA Montoya.

Based on the assessment and interview with the administrator and staff, the facility has five residents. Two residents were tested positive on 11/25/2021 and the other three residents were tested positive on 11/26/2021. Staff (S1 & S2) were tested negative for consecutive two weeks since the Covid-19 outbreak commenced in the facility. Martz stated S1 & S2 will continue to test for Covid-19 for another week as instructed by the Department of Public Health. Per LPA's review of the personnel report, there are seven (7) staff on the list including the administrator. Martz explained only S1 & S2 have been working since the Covid-19 outbreak at their own discretion. Martz explained she reported the outbreak to the Department of Public Health on 12/1/2021 and not to CCLD. Per record review, CCLD conducted an intake of the Covid-19 outbreak on 12/2/2021 with the administrator.

During today's visit, LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA observed a sanitizing station at the facility entrance; visitors log with COVID-19 screening and temperature log, and records of daily COVID-19 screening and temperature checks of residents and staff; vaccination records of staff and residents are kept in the facility; soap, paper and cleaning supplies were ample; and Covid-19 posters were observed.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), a deficiency was observed and is being issued a citation on LIC 809-D.

Exit interview was conducted with Administrator, Laura Martz. Due to a technical difficulty, LPA was not able to provide a hard copy of the report after the visit but an electronic copy was emailed to Administrator Martz, Appeal rights were provided.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: EMERALD ISLE ASSISTED LIVING #2
FACILITY NUMBER: 198201753
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2021
Section Cited

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by:
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Based on record review and interview, there were two residents tested Covid-19 positive on 11/25/2021 and additional three residents were tested positive. Licensee failed to report this incident within 24 hours. Licensee reported the incident to the Department of Public Health on 12/1/2021 and DPH informed CCLD on 12/2/2021. This poses an immediate health, safety and/or personal rights risk to residents in care.
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Type B
12/17/2021
Section Cited

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidence by:
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Licensee failed to report a Covid-19 outbreak to the department within 24 hours either by telephone or facsimile to the licensing agency. This poses a potential health, safety and/or personal rights risk to residents in care
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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: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021
LIC809 (FAS) - (06/04)
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