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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205023
Report Date: 05/28/2021
Date Signed: 05/28/2021 04:42:32 PM

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 HOMESFACILITY NUMBER:
198205023
ADMINISTRATOR:CHRISTINA WALLFACILITY TYPE:
740
ADDRESS:27651 TARRASA DRIVETELEPHONE:
(310) 351-7075
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 6DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Linsay NettingaTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Ana Soto and Jose Calderon conducted an unannounced Annual inspection visit and infection control inspection to the above facility. LPA was met by Lindsay Nettinga, Administrator and the purpose of today’s visit was explained.

There are currently (6) six Elderly consumers in placement. All (1) resident is ambulatory and (5) are non-ambulatory. The facility is a single story structure located in a residential neighborhood. It consists of the following: 6 bedrooms, 2 bathrooms, office area, living room, kitchen, dining room, shaded area, laundry room and an attached garage.

LPA's and Administrator toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms 1,2,3,4, are occupied by single residents and contain the mandated furniture. Bedroom 5 is a shared bedroom, Bedroom 6 is a staff bedroom. The (2) bathrooms are clean and operational. 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 and 1 resident file were complete. Medications are current. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or items are inaccessible to residents, 2 fire extinguisher 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. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, sanitizer/soap in the bathrooms and additional sanitation supplies are in the garage. LPA observed staff wearing masks, an isolation room are residents private rooms, for shared room the have a plan in place and required postings throughout the facility. The facility has an approved Mitigation plan. Visitors are logged and checked. The residents temperature's are checked and logged daily every 3 hours..

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.

An exit interview conducted with Lidsay Nettinga, Administrator and copy of report provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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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