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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201753
Report Date: 02/09/2023
Date Signed: 02/09/2023 11:06:02 AM


Document Has Been Signed on 02/09/2023 11:06 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY 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:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Christina MacasiebTIME COMPLETED:
11:00 AM
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On 2/9/2023 LPM Eva Alvarez and LPA Alfonso Iniguez conducted an unannounced annual visit. LPM and LPA met with House Manager/Joy Miran and Caregiver/Christina Macasieb. There are currently (5) residents residing in the facility. The facility is licensed to serve (6) elderly residents 59 and over. The faclity is approved to support (5) hospice and (1) bedridden residents. At this time, there is (1) ambulatory, (3) non-ambulatory, and (1) bedridden residents living in this facility.

The facility is a single-story structure located in a residential neighborhood. It consists (3) resident bedrooms, (1) staff room, (2) full bathrooms, kitchen, dining area, living room, and patio area with shade located in backyard. The facility entrance and exits are wheelchair accessible. The facility has (1) garage that is utlized for supplies.

LPM and LPA observed required posting at the entrance and throughout the facility. The facility smoke detectors and carbon monoxide detectors were tested are operational. The facility has night lights in hallways and restroom #1 has non-skid mats and grab bars. Restroom #2 is under construction due to water damage. The construction does not appear to interfere with residents daily routines or presenting a safety hazzard.

LPM and LPA observed a sign-in/sanitation station at the facility entry. Facility has screening process for visitors, sanitizer/soap, paper towels, and additional PPE supplies are stored in the garage. The facility is prepared to provide a private room for isolation if needed. The facility mitigation plan was approved by CCL on 5/16/2021.

No citations were issued during this visit. An exit interview was conducted with Chrisina Macasieb and copy of this report was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
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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