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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001407
Report Date: 05/16/2024
Date Signed: 05/16/2024 04:32:35 PM


Document Has Been Signed on 05/16/2024 04:32 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



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:299CENSUS: 263DATE:
05/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:Kathleen Panganiban, Assistant Executive DirectorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct a case management visit in conjunction with an unusual incident/Injury Report (LIC 624) received in our office on May 3,2024. LPA was greeted and granted entry by Karollyne Saveestasi, Customer Service Representative (CSR). During today’s visit, LPA met with Kathleen Panganiban, Assistant Executive Director (AED) and Dillon Cagulada, Executive Director (ED).

The facility is a large Residential Care Facility for the Elderly (RCFE). It is a triple story building attached with a two story building with an approved fire clearance for total capacity of 299; 259 non-ambulatory residents of which 40 may be bedridden. The three story building has Independent Living (IL), Assisted Living (AL) and Memory Care and the newer two story building is strictly for AL. The facility has an approved hospice waiver for 40 residents. The facility currently has a census of 263 residents in care.

During the visit LPA Ruppert requested the following documents: File for Resident #1 (R1) (LIC 858), file for Staff #1 (S1) (LIC 859), associate roster, insurance automobile claim form submitted after incident and a copy of the physician's report. Per Physician's Report dated March 14, 2024 resident is non-ambulatory with a primary diagnosis of altered mental status and MCI. LPA Ruppert interviewed the driver and resident regarding the incident.

Driver showed LPA where the incident occurred. Administrator has since installed an additional surveillance camera and provided receipt for the installation of audio back up chimes on the Ford Flex and Ford Transit Connect vehicles. A training was conducted on May 1, 2024 on "Procedure of Situational Awareness when Backing/Reversing" and a copy was provided. Facility self reported incident and cross reported to Community Care Licensing, the Long Term Care Ombudsman, Responsible Party and Physician.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiency cited on this date. An exit interview was conducted with AED Kathleen Panganiban and a copy of the report was given at the time of the visit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
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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