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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001407
Report Date: 08/11/2022
Date Signed: 08/11/2022 01:15:01 PM


Document Has Been Signed on 08/11/2022 01:15 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: DATE:
08/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Daizel Gasperian TIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to follow up on an incident report received on 8/3/22. Care staff had just checked on resident (R1) and a third party service provider went to R1's room and discovered R1 was not present at 5:56 am. It was reported that R1 broke a window screen, climbed through the window, climbed a fence and left the facility unassisted. The facility immediately imitated their elopement protocol and searched the facility. R1 eloped from the memory care unit. R1 was found outside the facility down the street by care staff at 6:30 am. R1 was screened and no injuries noted. R1 was taken back to the facility and his physician was notified. R1 is in the process of being conserved by the Orange County Public Guardian. Since the report R1 has not tried to elope from the facility. Violations 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 along with citations and Appeal Rights was provided to the Executive Director.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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 08/11/2022 01:15 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: EMERALD COURT
FACILITY NUMBER: 306001407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2022
Section Cited

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Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
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Based on interviews and record review, Licensee failed to ensure R1 was provided care and supervision. R1 eloped out of the facility and was discovered outside of the facility down the street. This poses an immediate health and safety risk to residents 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) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
LIC809 (FAS) - (06/04)
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