198205023-9-2-2022-11-AS-ASOO-CHVM5E-20220902091811

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205023
Report Date: 09/01/2022
Date Signed: 09/02/2022 09:18:34 AM

Document Has Been Signed on 09/02/2022 09:18 AM - 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 HOMES		FACILITY NUMBER:	198205023
ADMINISTRATOR:	CHRISTINA WALL		FACILITY TYPE:	740
ADDRESS:	27651 TARRASA DRIVE		TELEPHONE:	(310) 351-7075
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 6	DATE:	09/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Marylou Convocar, Care giver		TIME COMPLETED:	03:15 PM

NARRATIVE

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Licensing Program Analysts (LPA's) Ana Soto and Wendy Gibbs conducted an unannounced Annual required and infection control visit to the above facility. LPA's were met by Marylou Convocar, Care Giver and the purpose of today’s visit was explained.

There are currently (1) residents in the facility. (1) residents are ambulatory, (4) are non-ambulatory, (1) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (6) bedrooms, (2 1/2) bathrooms, mini outside ramps on all exit doors, egress system, back yard, front yard, shaded side patio, laundry room in attached 2 car garage.

LPA's and Marylou 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 have grab bars, non-skid mats, and/or chair and are clean and operational. First aid kit is fully stocked 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) Resident file along with medications are current. (1) Staff file was not current, CPR card expired 08/15/22. Ample supply of perishable and nonperishable food, Stove top knobs do not automatically light burners, staff using lighter to light burners, hot water temperature is (112.7) 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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

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 HOMES	FACILITY NUMBER: 198205023
	VISIT DATE: 09/01/2022

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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) No trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, No fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & IPhone for residents to use, resident’s temperatures are checked and logged (twice a day). 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 observed the following deficiency and issued a citation.

Technical Advisories (TA) issued:

1. No trash cans with lids in bathrooms.
2. No fit testing completed for staff.

An exit interview was conducted with Marylou Convocar, Care giver and a hard copy was provided via email along with Appeal Rights due to technical difficulties (printer.)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/02/2022 09:18 AM - It Cannot Be Edited

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 HOMES	FACILITY NUMBER: 198205023
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	87555(b)(29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This was not met as evidenced by: Based on Stove top knobs do not automatically light burners, which poses a potential health and safety risk for all persons in care.
	POC Due Date: 09/16/2022
	Plan of Correction
1 2 3 4	Administrator to repair burners to light automatically without lighter, to send invoice for repair to LPA Soto on or before POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4	87411 (c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This was not met as evidence by: based staff #1 CPR card expired 08/15/22. Which potentially poses a health and safety risk for all persons in care.
	POC Due Date: 09/08/2022
	Plan of Correction
1 2 3 4	Administrator to have staff get current CPR card and sent picture of new card to LAP by POC due date.

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC809 (FAS) - (06/04)

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