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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005159
Report Date: 11/22/2021
Date Signed: 11/22/2021 10:16:13 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
11/03/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20211103160551
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:
11/22/2021
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Jeanette SilvaTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility lighting fixture is missing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted a 10 day complaint visit to deliver findings on the above allegation. 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 toured the facility as well as interviewed staff and witnesses. Regarding the allegation that facility lighting fixture is missing, the investigation revealed the following: During the tour of the facility, LPA observed facility light fixture hanging in entrance of facility is missing. LPA observed a hanging cord only. Facility staff indicate there was a leak in the ceiling but fixture has not been replaced yet. 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 6
Control Number 22-AS-20211103160551
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: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2021
Section Cited
CCR
80087(a)
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The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not being met as evidenced by:
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Licensee to repair/ replace light fixture and forward proof to LPA by POC due date.
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Based on observation, Licensee failed to ensure light fixture is in good repair. This poses a potential 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 6
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
11/03/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20211103160551

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:
11/22/2021
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Jeanette SilvaTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility does not have 2-day perishable and 7 day non-perishable foods
Facility is in disrepair
Balanced diet not being provided to the clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted a 10 day complaint visit to deliver findings on the above allegations. 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 toured the facility and interviewed staff. Regarding the allegations that facility does not have 2-day perishable and 7 day non-perishable foods, Facility is in disrepair, and balanced diet not being provided to the clients, the investigation revealed the following: During the tour of the facility, LPA observed there is discoloration on the ceiling in the entry of the facility. Staff state that there was a leak that has been repaired. Staff state that facility has hired a contractor to replace the drywall/ paint. Facility staff turned on the burners on the cook top. One burner had difficulty starting. All other burners started up immediately. LPA observed the food supply in the facility. There are varied items and ample supply. Staff indicate the food was low during Regional Center inspection due to it being grocery day. Regional Center QA indicated that the only item missing during the QA's inspection was milk and the food supply was ample. CONTINUED ON LIC 9099C DATED 11/22/2021
Unsubstantiated
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: 3 of 6
Control Number 22-AS-20211103160551
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
VISIT DATE: 11/22/2021
NARRATIVE
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LPA observed ample food supply on two different occasions. Due to conflicting information, LPA is unable to corroborate allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with House Manager and a copy of this report was provided.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 6