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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005159
Report Date: 11/18/2021
Date Signed: 11/22/2021 10:12:48 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/16/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20211116160346
FACILITY NAME:EMERYWOOD BOARD & CARE HOMEFACILITY NUMBER:
306005159
ADMINISTRATOR:HERNANDEZ, MARISA CFACILITY TYPE:
735
ADDRESS:8522 EMERYWOOD DRIVETELEPHONE:
(714) 290-3809
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY:6CENSUS: 6DATE:
11/18/2021
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Jeannette SilvaTIME COMPLETED:
08:45 AM
ALLEGATION(S):
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Client left unsupervised
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced initial 10 day complaint investigation. LPA was greeted and granted entry into the facility by House Manager Jeanette Silva and explained the reason for the visit.
During the course of the investigation, LPA interviewed staff and clients as well as reviewed and obtained pertinent documentation such as IPP and staff schedule. Regarding the allegation that client left unsupervised, the investigation revealed the following: Facility staff and Client 1 (C1) confirm the client was left alone in the facility. Witnesses states S1 left to go grab lunch and did not advise anyone the staff was leaving. C1 states this was a one time incident and verbalized feeling safe in the facility.

The preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8). Exit interview conducted and a copy of this report was left at the facility as well as appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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 2
Control Number 22-AS-20211116160346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: EMERYWOOD BOARD & CARE HOME
FACILITY NUMBER: 306005159
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2021
Section Cited
CCR
80078(a)
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The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not being met as evidenced by:
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Licensee to provide a written statement on how to ensure all clients are provided care and supervision and forward to LPA by POC due date.
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Bassed on interviews conducted, Licensee failed to ensure C1 was provided care and supervision. This poses an immediate health and safety risk to clients 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2