306005159-5-23-2024-22-AS-DLMN-D5JQWN-20240523123212

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005159
Report Date: 05/23/2024
Date Signed: 05/23/2024 12:34:06 PM

Document Has Been Signed on 05/23/2024 12:34 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	EMERYWOOD BOARD & CARE HOME		FACILITY NUMBER:	306005159
ADMINISTRATOR/ DIRECTOR:	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: 5	DATE:	05/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Caregiver - Monique Jackson		TIME VISIT/ INSPECTION COMPLETED:	12:47 PM

NARRATIVE

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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Live-In Direct Service Provider Matthew Smith. LPA discussed the purpose of the inspection and Administrator (AD) Marisa Hernandez was contacted by phone. Direct Service Provider Monique Jackson arrived at the facility by 11:30am.

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. Other clients were away at day program. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested over 120 F degrees in client bathrooms. A deficiency is being issued.

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. Appliances are operational. Sharps were observed to be 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. LPA reviewed P&I and observed two of five clients' P&I to have inconsistencies with the most recent balance on the ledger. A deficiency is being issued.

Based on the observations made during today’s inspection, two deficiencies are 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 provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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 4

Document Has Been Signed on 05/23/2024 12:34 PM - It Cannot Be Edited

Created By: Dwayne L Mason On 05/23/2024 at 12:02 PM

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: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). 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 due to hot water measuring over 120 degrees Fahrenheit which poses an immediate safety risk to persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	Facility staff stated they will adjust the hot water heater and ensure that hot water temperature is between 105 and 120 degrees Fahrenheit. LPA stated they will verify the completion of the plan of correction at a follow-up inspection.

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:

Dwayne L Mason

LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 05/23/2024 12:34 PM - It Cannot Be Edited

Created By: Dwayne L Mason On 05/23/2024 at 12:02 PM

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: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80026(h)

Safeguards for Cash Resources, Personal Property and Valuables

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two out of five client P&I funds. This poses a potential personal rights risk to persons in care.
	POC Due Date: 06/06/2024
	Plan of Correction
1 2 3 4	Facility staff stated they will replenish funds missing from two client P&I funds. Adminsitrator also stated they will conduct another training on P&I management and documentation. AD stated they will document the training topics covered, staff in attendance and date of training. AD stated they will send to LPA via email documentation showing proof of training completed by staff. LPA stated they will verify completion of this plan of correction 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:

Dwayne L Mason

LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4