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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005159
Report Date: 05/30/2024
Date Signed: 05/30/2024 09:22:24 AM

Document Has Been Signed on 05/30/2024 09:22 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:EMERYWOOD BOARD & CARE HOMEFACILITY NUMBER:
306005159
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, MARISA CFACILITY TYPE:
735
ADDRESS:8522 EMERYWOOD DRIVETELEPHONE:
(714) 290-3809
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 6DATE:
05/30/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:13 AM
MET WITH:Live-In Direct Service Provider - Matthew Smith and Administrator - Marisa HernandezTIME VISIT/
INSPECTION COMPLETED:
09:37 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced visit for the purpose of conducting a Plan of Corrections Inspection for a deficiency issued on 5/23/2024. 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.

LPA measured hot water in the client bathrooms and observed temperatures to be 117.6 degrees Fahrenheit and 118.4 degrees Fahrenheit. The Plan of Corrections has been fulfilled by the assigned POC due date of 05/24/24 and the deficiency has been cleared.

An exit interview was conducted and Live-In Direct Service Provider Matthew Smith and Administrator Marisa Hernandez and a copy of this report was provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
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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