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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201803
Report Date: 03/22/2022
Date Signed: 03/22/2022 04:51:49 PM

Document Has Been Signed on 03/22/2022 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:EMILY'S HOME IVFACILITY NUMBER:
198201803
ADMINISTRATOR:FORTUNATO MARQUEZFACILITY TYPE:
735
ADDRESS:19011 EDDINGTON DRIVETELEPHONE:
(310) 378-3669
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 6CENSUS: 5DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Emelina Marqez, AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by administrator. LPA was later met by Emelina Marquez, Administrator and the purpose of today’s visit was explained. The facility is licensed to serve 6 developmentally disabled clients (age 18-59). Which 2 clients may be non-ambulatory.

There are currently (4) South Central Regional Center clients in placement. There were 0 clients present due to being at the day program. The facility is a single story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 2 bathrooms, dining room, kitchen, living room, indoor and outdoor shaded area, laundry room and an attached garage.

LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperatures measured at 108.7 and 107.7 F.A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is an enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

LIC 809-C is on the next page.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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
MONTEREY PARK, CA 91754
FACILITY NAME: EMILY'S HOME IV
FACILITY NUMBER: 198201803
VISIT DATE: 03/22/2022
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

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

During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the report was provided to Administrator

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC809 (FAS) - (06/04)
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