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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001407
Report Date: 12/02/2024
Date Signed: 12/02/2024 01:50:34 PM

Document Has Been Signed on 12/02/2024 01:50 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/
DIRECTOR:		DAIZEL C GASPERIANFACILITY TYPE:
740
ADDRESS:1731 MEDICAL CENTERTELEPHONE:
(714) 778-5100
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 299TOTAL ENROLLED CHILDREN: 0CENSUS: 241DATE:
12/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:E.D DellionTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst LPA Samer Haddadin conducted an unannounced visit for the purpose of completing a case management deficiency visit. LPA was met by Executive Director, Dillon (ED). LPA was granted entry to the building and then explained the reason for the visit.

On November 21, 2024, Community Care Licensing received an incident report from this facility regarding resident (R1) who eloped the building and was found by few good Samaritans. Today, LPA Haddadin visited the facility to review (R1) physician report in which it was determined that the resident was unable to leave the facility unassisted per medical record.

Based on the observation made today, deficiencies are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.

Alisa OrtizTELEPHONE: (714) 703-2855
Samer HaddadinTELEPHONE: (714) 790-2096
DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/02/2024 01:50 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: EMERALD COURT
FACILITY NUMBER: 306001407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by Resident 1 was able to elope from the facility
Deficient Practice Statement
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POC Due Date: 12/02/2024
Plan of Correction
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Facility has implemented monthly elopement drills, contracted a company to assess the facility and provide suggestions to deter elopements. Facility to send LPA Haddadin elopement in services by 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.
Alisa OrtizTELEPHONE: (714) 703-2855
Samer HaddadinTELEPHONE: (714) 790-2096

DATE: 12/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2024

LIC809 (FAS) - (06/04)
Page: 2 of 2