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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202539
Report Date: 11/11/2023
Date Signed: 11/11/2023 12:25:01 PM


Document Has Been Signed on 11/11/2023 12:25 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:EMERALD ISLE ASSISTED LIVING IIIFACILITY NUMBER:
198202539
ADMINISTRATOR:LINDSEY NETTINGERFACILITY TYPE:
740
ADDRESS:27781 HAWTHORNE BLVDTELEPHONE:
(310) 544-3308
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 3DATE:
11/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:LINDSEY NETTINGERTIME COMPLETED:
12:54 PM
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On 11/11/2023 at 9:03 am Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection.

LPA was met by Sarah Maria Reyes, caregiver and the purpose of today’s visit was explained. During the visit, LPA observed the facility infection control practices. There are currently three (3) residents in the facility. There are three (3) residents are non-ambulatory, and (2) bedridden. The facility is a single-story structure located in a residential neighborhood. The Residential Care Facilities for the Elderly (RCFE) is licensed to serve (6) bedridden clients age 60 and above, may retain (1) hospice client at any given time. The facility consists of five (5) bedrooms, two (2) full bathrooms, shaded back yard, front yard, pool with gate, laundry room and a detached two (2) car garage. LPA and Sarah Maria Reyes toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1, 2 and 3 are occupied by residents and contain the mandated furniture. Bedroom 7 is a staff bedroom. The three and half (3 1/2) bathrooms have grab bars and non-skid mats and are clean and operational.

First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detectors were in compliance and operational. No firearms are stored at facility and body of water present (pool with gate.) Medications are stored, locked and inaccessible to residents. Resident files along with medications are current. Staff files are current. Ample supply of perishable and nonperishable food, hot water temperature is (116.6) degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (1) fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: EMERALD ISLE ASSISTED LIVING III
FACILITY NUMBER: 198202539
VISIT DATE: 11/11/2023
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LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. Emergency contacts updated and posted; PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

Technical Advisory (TA) issued.

Resident Rights/Information - Technical Violation: 87468(c)(2)(A)

An exit interview conducted with Cecenirose Pare, Caregiver and a hard copy of report was provided

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2023
LIC809 (FAS) - (06/04)
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