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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001407
Report Date: 09/08/2021
Date Signed: 09/08/2021 02:03:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:EMERALD COURTFACILITY NUMBER:
306001407
ADMINISTRATOR:PATRICIA GIRAY-GUSTINFACILITY TYPE:
740
ADDRESS:1731 MEDICAL CENTERTELEPHONE:
(714) 778-5100
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:123CENSUS: 115DATE:
09/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Daziel Gasperian, Nikkianna DyerTIME COMPLETED:
02:21 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. The Agency (CCL) received a report of suspected abuse concerning a resident (R1). LPA was greeted and granted entry by Executive Director (ED) Daziel Gasperian and Assistant Executive Director (AED) Nikkianna Dyer. LPA explained the reason for the visit. LPA interviewed the Executive Director and Assistant Executive Director. The incident occurred 9/3/2021 around 4:00pm. Staff reported the incident the next day to the Assistant Executive Director. On 9/4/2021 Assistant Executive Director contacted the Anaheim Police Department and provided them with the details of the incident. Law Enforcement did not go to the facility. The Resident (R1) did not require medical attention and the facility has been monitoring R1 who is reported to be doing well. LPA interviewed staff and R1. LPA requested documents, admission agreement, physician's report and needs and care plan for R1. No citations are being issued as a result of this visit. An exit interview was conducted and a copy of this report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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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