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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001407
Report Date: 06/21/2022
Date Signed: 06/21/2022 04:49:18 PM


Document Has Been Signed on 06/21/2022 04:49 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
CCLD Regional Office, 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:139CENSUS: 138DATE:
06/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:56 PM
MET WITH:Daizel Gasperian, Kathleen PanganibanTIME COMPLETED:
04:57 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA was greeted and granted entry by staff. LPA met with Administrator Daizel Gasperian and Assisted Living Director Kathleen Panganiban. LPA explained the reason for the visit. The Agency (CCL) received an unusual incident report on 6/17/2022 reporting that a resident had an incident on a motorized mobility scooter on 6/10/2022. The incident report stated that on this day Resident 1 & 2 left the facility and Resident 2 (R2) returned to the facility after being separated from R1. R2 contacted a police officer who was passing by. Upon returning to the facility the police and R2 informed the facility R1 was with R2 but they were separated and they do not know where R1 is. R1 was found by the facility Administrator and brought back to the facility. R1 & R2 were assessed and no injuries observed, no first aid required. Through a review of records it was determined that R1 is not able to leave the facility unassisted. R2 who is married to R1 is allowed to leave the facility unassisted. The police informed the facility both residents seem fine and no further assistance is required and left the facility. When the facility was made aware that R1 was not accounted for they started searching for R1 and found them close to the facility and returned him. R2 is allowed to leave the facility with R1. The facility acted properly during the incident and did all they could to assist the residents. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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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