306005159-3-27-2023-22-AS-CGUZ-CQBPFF-20230327111639

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005159
Report Date: 03/27/2023
Date Signed: 03/27/2023 11:16:47 AM

Document Has Been Signed on 03/27/2023 11:16 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 HOME		FACILITY NUMBER:	306005159
ADMINISTRATOR:	HERNANDEZ, MARISA C		FACILITY TYPE:	735
ADDRESS:	8522 EMERYWOOD DRIVE		TELEPHONE:	(714) 290-3809
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90621
CAPACITY: 6		CENSUS: 6	DATE:	03/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jasmine Werdel		TIME COMPLETED:	11:30 AM

NARRATIVE

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Licensing Program Analysts (LPAs) Claudia Gutierrez and Dwayne Mason made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs were greeted and granted entry by Staff Jasmine Werdel. LPA discussed the purpose of the inspection and Administrator (AD) Marisa Hernandez was contacted by phone and arrived at 11:00 a.m.

During the inspection LPAs and Staff Werdel conducted a tour of the inside and outside of the facility, common areas, client rooms, staff room, kitchen, garage and observed the following:

This is a two-story house with six client bedrooms, three bathrooms, and one staff bedroom. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The back yard has a shaded sitting area. LPA observed one staff and two clients present. Per Staff Werdel, two clients were away at day program and two additional clients were at their day jobs. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 119.4 F degrees.

LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted at the entrance of the facility. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Kitchen refrigerator tested inoperable; a Deficiency was issued on today’s date. Sharps were observed locked in the pantry. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication was observed to be locked. The first aid kit has all the required elements. LPA reviewed three client files and three staff files. LPA interviewed two clients and one staff.

Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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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Document Has Been Signed on 03/27/2023 11:16 AM - It Cannot Be Edited

Created By: Claudia Gutierrez On 03/27/2023 at 10:30 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) 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 met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as kitchen refrigerator was not operational which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/27/2023
	Plan of Correction
1 2 3 4	AD stated they would provide LPA with invoice regarding repair of refrigerator by POC date via email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Claudia Gutierrez

LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC809 (FAS) - (06/04)

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