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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201753
Report Date: 01/17/2024
Date Signed: 01/17/2024 02:09:09 PM

Document Has Been Signed on 01/17/2024 02:09 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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: 6DATE:
01/17/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Ceceni Rose Pare/ AdministratorTIME COMPLETED:
02:08 PM
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On 1/17/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Ceceni Rose Pare/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above ambulatory/non-ambulatory. Dementia waiver on file. Approved hospice waiver for (2).


The facility is a single-story structure located in a residential neighborhood. It consists of (5) 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 utilized for supplies.

LPA Iniguez toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (5) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected the carbon monoxide detectors combo were in operable conditions. The water temperature properly measured between 105°-120°F: Kitchen 109.7°F, Bathroom #1:112.7°F, Bathroom #2:109°F.

Evaluation Report Continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: EMERALD ISLE ASSISTED LIVING #2
FACILITY NUMBER: 198201753
VISIT DATE: 01/17/2024
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LPA Iniguez observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene, sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. A review of (3) residents' service files, (2) staff personnel files and (3) Medication Administration Records (MAR) LPA did not find discrepancies. The first AID kit was checked. Last facility disaster drill was: 12/11/23.

LPA observed the facility's infection control practices. A copy of the liability insurance will be emailed to LPA.



Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8.



An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Ceceni Rose Pare /Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
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Document Has Been Signed on 01/17/2024 02:09 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 01/17/2024 at 01:54 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EMERALD ISLE ASSISTED LIVING #2
FACILITY NUMBER: 198201753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation , the licensee did not comply with the section cited above in having unlocked cleaning supplies underneath the kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2024
Plan of Correction
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 Care staff locked the cleaning supplies while LPA was at the facility. Licensee will ensure all cleaning supplies are locked at all time. As POC, licensee will re-train care staff regarding keeping cleaning supplies locked at all time. Licensee will sent proof of correction to LPA via email before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


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