198202539-9-18-2024-11-AS-SLEO-D94TP9-20240914145359

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198202539
Report Date: 09/14/2024
Date Signed: 09/18/2024 12:33:37 PM

Document Has Been Signed on 09/18/2024 12:33 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/16/2024 01:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

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	This document is amended to update the number of approved bedridden residents. On 09/14/2024 at around 9:40 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Licensee Assistant Cecenirose Pare. LPA explained the purpose of the visit and was accompanied by staff inside and outside the facility during this inspection. This facility is licensed to serve 6 bedridden residents ages 60 and above. Complaint with 87705 - Care of Persons with Dementia. Approved for 1 Hospice resident at any given time. There are a total of 5 residents residing in this facility. There are a total of 2 hospice residents residing in this facility. There are a total of 1 bedridden resident in this facility. The facility is a one-story house located in a residential street. The home consists of 4 resident bedrooms, 1 staff bedroom, 3 bathrooms, 1 kitchen, 1 dining/living room area, 1 backyard swimming pool, 1 attached garage,1 backyard patio area with shaded seating.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024

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 4

Document Has Been Signed on 09/18/2024 12:34 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/16/2024 01:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: EMERALD ISLE ASSISTED LIVING III	FACILITY NUMBER: 198202539
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87204(a)

Limitations -Capacity and Ambulatory Status

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in having 2 residents who are under hospice care. The Facility License is approved for "1 hospice client at any given time" which poses a potential health to persons in care.
	POC Due Date: 10/01/2024
	Plan of Correction
1 2 3 4	The Licensee agrees to submit a capacity increase for their Hospice Waiver. Licensee will email request to Socorro.Leandro@dss.ca.gov and follow directions for approval.

Type B

Section Cited

CCR

87506(a)

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, and interview conducted, the licensee did not comply with the section cited above in not having a complete and current record of the Medication Administrator Record (MAR) for Residents (LPA observed several mistakes on the MAR), which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 10/01/2024
	Plan of Correction
1 2 3 4	The licensee agrees to retrain staff on how to provide medications to residents in care and how to document Medication Administration Record (MAR). Licensee will email staff trainings to Socorro.Leandro@dss.ca.gov.

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: EMERALD ISLE ASSISTED LIVING III	FACILITY NUMBER: 198202539
	VISIT DATE: 09/14/2024

NARRATIVE

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The patio furniture is under a shaded area and accessible to residents. There are no security bars or weapons on the premises. There is construction currently happening in the facility.

LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.

LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There is a fire extinguisher in the kitchen and it was last serviced on 09/05/2024.

5 out of 5 bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: EMERALD ISLE ASSISTED LIVING III	FACILITY NUMBER: 198202539
	VISIT DATE: 09/14/2024

NARRATIVE

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5 staff records were reviewed, 3 out of 5 staff records had required documentation. 2 out 5 staff files were incomplete.

5 resident records were reviewed and, 5 out of 5 resident records had required documentation.

A technical assistance is being issued for: videoconferencing devices dedicated for client use, maintaining complete files in the facility, and facility construction or alterations.

LPA explained to Licensee Assistant to contact their designated LPA Leon and inform them of their construction plan. Email: Mario.Leon@dss.ca.gov

Deficiencies are being cited based on LPA observation, record review and interviews conducted in accordance with the California Code of Regulations, Title 22. Violation regarding: Hospice Waiver, Fire Clearance for Bedridden Residents, and Complete & Current Medication Administration Records (MAR).

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Licensee Assistant.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024

LIC809 (FAS) - (06/04)

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