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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001407
Report Date: 06/02/2023
Date Signed: 06/02/2023 10:04:02 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/21/2022 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221121095024
FACILITY NAME:EMERALD COURTFACILITY NUMBER:
306001407
ADMINISTRATOR:DAIZEL C GASPERIANFACILITY TYPE:
740
ADDRESS:1731 MEDICAL CENTERTELEPHONE:
(714) 778-5100
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:139CENSUS: 228DATE:
06/02/2023
UNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Assitant Executive Director Kathleen PanganibanTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident was given an unlawful eviction
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to deliver findings on complaint investigation. LPA was granted entry by staff. LPA discussed purpose of the visit with Assitant Executive Director Kathleen Panganiban.

During the course of this investigation LPA toured facility, conducted interviews with staff and gathered pertinent documents. It was alleged that "Resident was given an unlawful eviction". Based on information received in interviews and review of documents, investigation revealed that on 10/24/22 resident (R1) signed a 'Notice of Intent to Vacate". Investigation also revealed that during an incident in which resident was getting sent out to hospital due to change in behavior, resident complained of items missing and gave staff member (S1) permission to look through bags, while looking for items S1 found Mase and a Taser located in residents bag at which point facility confiscated items due to resident breaking house rules. Facility issued a 3 day eviction notice to responsible party on 11/18/22.
CONTINUED ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20221121095024
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EMERALD COURT
FACILITY NUMBER: 306001407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
06/05/2023
Section Cited
CCR
87224(b)
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The licensee may, upon obtaining prior written approval from the licensing agency evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior which is a
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Licensee to review the regulatory requirements for eviction procedures and provide an in-service training to all staff regarding the adequate procedure required prior to conducting a client's eviction. Licensee to provided proof of training.
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threat to the mental and/or physical health or safety of himself or to others in the facility. This requirement is not met as evidenced by facility did not comply with proper eviction procedures which poses an immediate health, safety or personal rights risk to persons in care.
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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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 22-AS-20221121095024
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: EMERALD COURT
FACILITY NUMBER: 306001407
VISIT DATE: 06/02/2023
NARRATIVE
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Resident was discharged to family after leaving hospital and last day of billing from facility was 11/23/22. During the time the allegations were stated, Resident was residing in facility. The required steps towards an 3 Day eviction procedure were observed to not have been met by the facility prior to residents discharge.

Based off information received and timeline of events, the department has found, the preponderance of evidence standard has been met, therefore the above allegation Resident was given an unlawful eviction is deemed to be SUBSTANTIATED per California Code of Regulations, (Title 22, Division 6, Chapter 8).

An exit interview was conducted with Assitant Executive Director and a copy of this report, along with a LIC 811 form, copy of citation and copy of Appeal Rights have been provided to Facility.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3