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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205023
Report Date: 05/13/2024
Date Signed: 05/13/2024 12:04:24 PM


Document Has Been Signed on 05/13/2024 12:04 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 HOMESFACILITY NUMBER:
198205023
ADMINISTRATOR:CHRISTINA WALLFACILITY TYPE:
740
ADDRESS:27651 TARRASA DRIVETELEPHONE:
(310) 351-7075
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 5DATE:
05/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Ceceni Rose Pare/AdministratorTIME COMPLETED:
12:03 PM
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On 5/13/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Ceceni Rose Pare /Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) elderly adults ages 60 and above of which (6) can be non-ambulatory. Facility has an approved hospice waiver for (6).

The facility is a single-story structure located in a residential neighborhood. It consists of (5) bedrooms, (3) full bathrooms, living room, dining room, kitchen, shaded back yard, front yard, laundry room and attached 2 car garage.

LPA Iniguez toured the physical plant with Administrator. There were no bodies of water or obstructions on the premises. A total of (3) 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 (5) rooms and (2) bathrooms. Smoke and carbon monoxide are all operable conditions. The water temperature ranged from 115.5F° – 116.2F°. The room temperature ranged from 76F° – 78F°.

Evaluation Report continues on LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024
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 HOMES
FACILITY NUMBER: 198205023
VISIT DATE: 05/13/2024
NARRATIVE
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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. 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 3/25/24.

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

LPA observed the facility's infection control practices. All mandated inspection control posters were posted throughout the facility. Copy of liability insurance was email to LPA. Facility Annual Fess current.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-Unlocked cleaning supplies found underneath kitchen sink and a resident’s bathroom. (Pictures taken by LPA).

-No current LIC 602A for (R#1). Primary diagnosis requires medical assessment every year.

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

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2024 12:04 PM - 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: EMERALD ISLE ASSISTED LIVING HOMES
FACILITY NUMBER: 198205023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) , the licensee did not comply with the section cited above in having unlocked cleaning supplies underneath kitchen sink and one of the resident's bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Licensee will ensure all cleaning supplies are locked at all times. As Plan of Correction, licensee will re-train all facility staff regarding how to keep cleaning solutions locked and away from residents in care. A proof of training will be sent to LPA before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/13/2024 12:04 PM - 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: EMERALD ISLE ASSISTED LIVING HOMES
FACILITY NUMBER: 198205023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having a current LIC 602A for (R#1) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2024
Plan of Correction
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Licensee will ensure residents with SHN will have at least a LIC 602A every year. As Plan of correction, licensee will submitt a recent LIC 602A for (R#1). A copy will be sent to LPA via email before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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