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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005159
Report Date: 07/22/2024
Date Signed: 07/22/2024 02:53:59 PM

Document Has Been Signed on 07/22/2024 02:53 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 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:
07/22/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:26 PM
MET WITH:Caregiver - Monique JacksonTIME VISIT/
INSPECTION COMPLETED:
03:09 PM
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On 7/22/2024, LPA arrived at the facility unannounced for the purpose of following up on the plan of correction issued at the 5/23/2024 annual inspection. During the 5/23/2024 inspection, the facility was issued a citation due to discrepancies in two of the six clients' P&I funds.

LPA met with Monique "Mo" Jackson and explained the nature of the inspection. LPA observed three clients to be home. Clients were taking showers, cleaning and getting ready to go to work or get picked up.

LPA reviewed the P&I for all six clients. Based on review of P&I funds, LPA determined that all of the funds are accurate. Based on today's inspection, LPA determined that the facility fulfilled their plan of correction by the assigned POC due date. LPA reviewed this report with facility staff and provided the LIC809 and clear letter to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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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