306005159-11-22-2021-22-AS-AORZ-C9K3J5-20211209171657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005159
Report Date: 11/22/2021
Date Signed: 11/22/2021 10:14:19 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2020 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20200714110155

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:	11/22/2021
		UNANNOUNCED	TIME BEGAN:	08:46 AM
MET WITH:	Jeanette Silva		TIME COMPLETED:	09:46 AM

ALLEGATION(S):

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Client walking down street alone/unattended
Client was left in facility alone
Clients hygiene was unkempt - food stains on his face and clothing
Facility does not have enough staff to fulfill clients needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility by House Manager Jeanette Silva and explained the reason for the visit.
During the course of the investigation, LPA Velazquez interviewed staff and witness. LPA Lyman interviewed staff and witness as well as reviewed and obtained pertinent documentation such as C1's IPP. Regarding the allegations that client walking down street alone/unattended, client was left in facility alone, clients hygiene was unkempt - food stains on his face and clothing, and facility does not have enough staff to fulfill clients needs, the investigation revealed the following: It was reported that C1 left the facility and walked alone to the client's job coach vehicle. C1 denies the incident and states he waits at the gate for the job coach. Sometimes the client gets excited to see the job coach but waits on the facility property. LPA observed the current job coach arrive on the property and C1 advised staff the job coach was there and went outside to meet the coach. Interviews conducted by LPA Velazquez indicate staff was present at the facility during the incident in question. CONTINUED ON LIC 9099C DATED 11/22/2021.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200714110155

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/22/2021

NARRATIVE

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C1's IPP dated 05/20/2021 indicate client and facility are working on C1's hygiene. Staff present during the incident indicate the client had been showered and shaved but the client grabbed additional food and may have spilled. C1 states staff assist client in hygiene before the client leaves for work and LPA observed client to be clean and well kempt during visit. LPA observed staff shaving another client. LPA interviewed staff regarding staffing schedule and requested schedule from Administrator. Generally there is one staff working in the morning to assist the clients. Clients living in the facility are high functioning. Due to conflicting information, LPA is unable to corroborate allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with House Manager and a copy of this report was provided.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

LIC9099 (FAS) - (06/04)

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