198203823-4-22-2022-11-AS-ASOO-CDPRZ9-20220421132734

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198203823
Report Date: 04/21/2022
Date Signed: 04/22/2022 04:47:31 PM

Document Has Been Signed on 04/22/2022 04:47 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:	EMERALD ISLE ASSISTED LIVING		FACILITY NUMBER:	198203823
ADMINISTRATOR:	MARTZ, LAURA		FACILITY TYPE:	740
ADDRESS:	6607 EL RODEO RD.		TELEPHONE:	(310) 351-7075
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 5	DATE:	04/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Heather Ludwick-Duncan		TIME COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required visit and an infection control inspection to the above facility. LPA met with Ceceni Perez, House Manager and later met with Heather Ludwick-Duncan, Administrator the purpose of today’s visit was explained.

There are currently (5) residents in the facility. (3) residents are ambulatory and (2) are non-ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists (6) bedrooms, (2) full and 1/2 bathrooms, shaded back yard, front yard, laundry room in the attached 2 car garage.

LPA and Ceceni toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-5 are occupied by residents and contain the mandated furniture. Bedroom 6 is a staff bedroom. The (2 1/2) bathrooms are clean and operational. First aid kit completes with manual smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. 1 staff file complete and 1 resident file with medications are current and complete. Ample supply of perishable and nonperishable food, hot water temperature is 120 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 1 fire extinguishers are 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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

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: EMERALD ISLE ASSISTED LIVING	FACILITY NUMBER: 198203823
	VISIT DATE: 04/21/2022

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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged, and temperature checked, sanitizer/soap in the bathrooms and additional sanitation supplies are stored in cabinet & closet around facility. LPA observed staff wearing masks, residents’ private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The facility has an approved Mitigation plan. The resident’s temperatures are checked and logged twice a day. PPE's are enough for 30 days. The facility had technical violations for infectious control domain. The facility did not have trash cans with lids or PPE cart or Fit testing done for all staff.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), no citations were issued. Three technical violations were issued at this time.

An exit interview conducted with Heather Ludwick-Duncan Administrator and a hard copy of report provided along with technical violations.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC809 (FAS) - (06/04)

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