198201753-1-24-2025-11-AS-JCAN-DD8RE5-20250124115659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198201753
Report Date: 01/24/2025
Date Signed: 01/24/2025 04:51:49 PM

Document Has Been Signed on 01/24/2025 04:51 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 #2		FACILITY NUMBER:	198201753
ADMINISTRATOR/ DIRECTOR:	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	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	01/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	ADMINISTRATOR LAURA MARTZ		TIME VISIT/ INSPECTION COMPLETED:	12:00 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	On 01/24/2025 at 09:00 AM, Community Care Licensing Division (CCLD) conducted an unannounced annual inspection visit at the Emerald Isle Assisted Living 2 Facility. CCLD staff was allowed entry into the facility by Administrator Laura Martz. Administrator Martz asked infection control questions and took CCLD staff temperature prior to entrance into the facility. Facility is to operate a Residential Care Facility for 6 Elderly residents 60 years or older. Currently, there are six (6) residents residing in the facility, 60 and older. CCLD staff explained to Administrator Martz, the purpose of the one-year Annual Inspection visit, and escorted CCLD staff on a tour of the entire inside and outside facility grounds. As part of the inspection, CCLD staff reviewed: Six (6) residents service records, six (6) residents medication records (MAR), three (3) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 12/10/2024. The one-story residential home consists of four (4) resident bedrooms, two (2) resident bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage and kitchen area.

Ulysses Coronel	TELEPHONE: (323) 400-7397
Jose Calderon	TELEPHONE: (323) 213-1153
	DATE: 01/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EMERALD ISLE ASSISTED LIVING #2	FACILITY NUMBER: 198201753
	VISIT DATE: 01/24/2025

NARRATIVE

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CCLD staff observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. CCLD staff observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, CCLD staff observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. CCLD staff observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 113 degrees Fahrenheit; bathroom #2 hot water temperature properly measured at 111 degrees Fahrenheit. Kitchen hot water temperature properly measured at 115 degrees Fahrenheit. Facility (2) Carbon Monoxide and (10) Smoke Detectors hard wired operated and connected were tested and are working properly. The facility one (1) Fire Extinguishers was checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. The facility has a working landline telephone. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility 2 first aid kit is fully stocked with manuals was checked and in order. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. Six (6) resident files were reviewed and found to be complete. CCLD staff reviewed six (6) resident medications (MAR) and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. CCLD staff noted the Administrator Laura Martz Certification # 6061671740 expiration date of 6/5/2025 was valid at time of inspection. The facility does not handle residents money/cash resources and no surety bond is needed. Commercial General Liability Policy #PCI2130019501 policy period from 05/08/2024 to 05/08/2025 underwritten by Primary Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Valencia to email CCLD staff a full copy of the commercial insurance policy including all endorsements no later than 02/10/2025. All the required documents are posted in the facility in a clearly visible area.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EMERALD ISLE ASSISTED LIVING #2	FACILITY NUMBER: 198201753
	VISIT DATE: 01/24/2025

NARRATIVE

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During the visit, CCLD staff observed the facility infection control practices. CCLD staff observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). CCLD staff observed staff and residents were NOT wearing face coverings. CCLD staff observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

CCLD staff advised the Administrator Martz to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), CCLD staff did observe deficiencies therefore citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Laura Martz.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

LIC809 (FAS) - (06/04)

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