198201803-3-16-2023-11-AS-PSCT-CPYR8U-20230316124830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198201803
Report Date: 03/16/2023
Date Signed: 03/16/2023 12:48:39 PM

Document Has Been Signed on 03/16/2023 12:48 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	EMILY'S HOME IV		FACILITY NUMBER:	198201803
ADMINISTRATOR:	FORTUNATO MARQUEZ		FACILITY TYPE:	735
ADDRESS:	19011 EDDINGTON DRIVE		TELEPHONE:	(310) 378-3669
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY: 6		CENSUS: 5	DATE:	03/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Emelina Marquez		TIME COMPLETED:	01:15 PM

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On 3/16/23 Licensing Program Analysts (LPAs) Perry Scott, Alfonso Iniguez, and Licensing Program Manager (LPM) Janae Hammond conducted an unannounced Annual required visit to the above facility. LPA was met by Emelina Marquez, Licensee, and the purpose of today’s visit was explained. The facility is licensed to operate for (4) ambulatory, (2) non-ambulatory clients ages 18-59 years old. None of the clients have a Restricted Health Care Condition and none are utilizing postural supports or protective devices. The facilities annual fees are current.

There are currently (5) South Central Los Angeles Regional Center (SCLARC) clients in placement. All (5) clients are ambulatory. The facility is a two-story home located in a residential neighborhood. It consists of the following: 3 client bedrooms, 1 staff bedroom, 2 bathrooms, office, living room, kitchen, dining room, attached garage which houses the washer and dryer.

LPA toured the inside and outside of the facility, along with the licensee. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed , plenty of dresser and closet space was observed. Walls and floors were clean and 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 regulation. Toilets and water faucets worked properly.

Report continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EMILY'S HOME IV	FACILITY NUMBER: 198201803
	VISIT DATE: 03/16/2023

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Shower was free of mold/mildew, adequate lighting, and sufficient toiletries accessible to clients. Water temperature properly measured 110.4 degrees F.

Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients.

Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Client and staff files were reviewed. All staff are fingerprint cleared and associated to the facility and have documentation of the required trainings on file. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

LPA conducted a records review of (5) client records, (5) staff records, (5) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (5) Client Medication Administration Records and did not observe any discrepancies at the time of visit. The last fire/emergency drill was performed on 2/18/2023.

During today’s visit, no deficiencies were observed.

An exit interview was conducted, and a copy of this facility evaluation report was provided to Emelina Marquez, Licensee.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC809 (FAS) - (06/04)

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