198201753-9-9-2022-11-AS-ASOO-CHUR5S-20220901124338

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198201753
Report Date: 09/01/2022
Date Signed: 09/09/2022 08:09:24 AM

Document Has Been Signed on 09/09/2022 08:09 AM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	EMERALD ISLE ASSISTED LIVING #2		FACILITY NUMBER:	198201753
ADMINISTRATOR:	MARTZ, LAURA DAWN		FACILITY TYPE:	740
ADDRESS:	28016 CALZADA DR.		TELEPHONE:	(310) 351-7075
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90274
CAPACITY:	6	CENSUS: 5	DATE:	09/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Joy Miran, House Manager		TIME COMPLETED:	01:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analysts (LPA's) Ana Soto and Wendy Gibbs conducted an unannounced Annual required and infection control visit to the above facility. LPA's were met by Joy Miran, House Manager and the purpose of today’s visit was explained.

There are currently (5) residents in the facility. (1) residents are ambulatory, (3) are non-ambulatory, (1) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (5) bedrooms, (2) full bathrooms, The facility has 4 mini rams on the outside doors, 1 ramp inside the garage, shaded back porch, front yard, laundry room in the attached 2 car garage.

LPA and Joy toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. Bedroom 5 is a staff bedroom. The (2) bathrooms that contain; grab bars and non-skid mats and are clean and operational. First aid kit is fully stocked with manual; smoke detectors were inter-connected and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is 109.9 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (1) fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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
MONTEREY PARK, CA 91754

FACILITY NAME: EMERALD ISLE ASSISTED LIVING #2	FACILITY NUMBER: 198201753
	VISIT DATE: 09/01/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, signs in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff wearing masks, resident private rooms will be converted to isolation rooms (if needed) No trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, No fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & IPhone for residents to use, resident’s temperatures are checked and logged (twice a day). Emergency contacts updated and posted; PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

Technical Advisories (TA) issued.

1 No trash can w/lid in bathroom

2. No fit testing completed for staff.

An exit interview conducted with Joy Miran, House manager and a hard copy of report provided.

Due to technical difficulties (printer) LPA will email report.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4