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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005159
Report Date: 05/24/2022
Date Signed: 05/24/2022 10:50:46 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/24/2022 10:50 AM - 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: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:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Jeanette Silva, Direct Support Professional and Marisa Hernandez, Administrator (Via telephone)TIME COMPLETED:
10:50 AM
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 On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual Inspection. LPA Quiroz was greeted and granted entry into the facility by Direct Support Professional (DSP) Jeanette Silva. Facility is a Level 3 Facility. LPA Rosie Quiroz explained the nature of the visit. (DSP) Silva indicated all incoming visitors are COVID-19 screened prior to entering the facility. During today's visit, LPA Quiroz called and spoke to Adminsitrator Marisa Hernandez and discussed the purpose for today's visit. (AD) Marisa Hernandez has an Administrator's certificate with an expiration date of March 31, 2023.
On or about 9:23am, LPA Quiroz along with (DSP) Silva began the tour of the inside and outside of the facility. There are six clients in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed Client 3 in his bedroom playing video games. (DSP) Silva indicated " All the other clients are at work right now." Client 3 who was present at the facility during today's visit appeared to be clean and well taken care of. LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility.
On or about 10:15am, LPA Rosie Quiroz reviewed clients records. All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within normal limits. LPA Quiroz inspected client’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water in kitchen and garage area readily available for staff and clients. LPA Quiroz toured the outside of the facility and observed table and chairs in backyard area for clients and visitor's enjoyment. LPA Quiroz observed locked and secured swimming pool.

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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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: EMERYWOOD BOARD & CARE HOME
FACILITY NUMBER: 306005159
VISIT DATE: 05/24/2022
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The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on June 07, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated
June 27 ,2021. LPA Quiroz was informed that "all clients and staff have had their COVID-19 vaccinations and first booster" Facility is recording client's temperatures daily, two times per day.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. An LIC 9102 AN (Advisory Note) issued during today's visit. (PLEASE SEE LIC 9102 TV)

During today's visit, LPA Quiroz provided Consultation on Title 22 and COVID-19 Infection Control throughout today's visit.

This report was reviewed with (DSP) Jeanette Silva and Administrator Marisa Hernadez via telephone, and a copy of this report and LIC 811 Confidential Names were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
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