198203823-4-29-2024-11-AS-AINZ-D4SUJW-20240429153813

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198203823
Report Date: 04/29/2024
Date Signed: 04/29/2024 03:44:10 PM

Document Has Been Signed on 04/29/2024 03:44 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

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: 6	DATE:	04/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Ceceni Rose Pare /Staff.		TIME COMPLETED:	03:45 PM

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On 4/29/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Ceceni Rose Pare /Staff. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) elderly adults ages 60 and above. Facility has an approved hospice waiver for (6).

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

LPA Iniguez toured the physical plant with Executive Director. There were no bodies of water or obstructions on the premises. A total of (8) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected (4) rooms and (1) bathrooms. Smoke and carbon monoxide are all operable conditions. The water temperature ranged from 113.5F° – 115.2F°. The room temperature ranged from 76F° – 78F°.

Evaluation Report continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EMERALD ISLE ASSISTED LIVING	FACILITY NUMBER: 198203823
	VISIT DATE: 04/29/2024

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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed. Cleaning supplies, toxins, and sharps objects were stored and not accessible to residents in care. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 3/18/24.

A review of (3) residents' service files and (3) staff personnel files were maintained in order. LPA reviewed (3) Medication Administration Records (MARs) and no discrepancies were found.

LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted throughout the facility. Facility Annual Fess are Current.

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

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Ceceni Rose Pare /Staff.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

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