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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005159
Report Date: 08/30/2024
Date Signed: 08/30/2024 10:47:30 AM

Substantiated


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
08/27/2024 and conducted by Evaluator Claudia Gutierrez
COMPLAINT CONTROL NUMBER: 22-AS-20240827153500
FACILITY NAME:EMERYWOOD BOARD & CARE HOMEFACILITY NUMBER:
306005159
ADMINISTRATOR:HERNANDEZ, MARISA CFACILITY TYPE:
735
ADDRESS:8522 EMERYWOOD DRIVETELEPHONE:
(714) 290-3809
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY:6CENSUS: 6DATE:
08/30/2024
UNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Matthew SmithTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff yells at clients.
INVESTIGATION FINDINGS:
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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA was greeted and granted entry by Staff Matthew Smith. Administrator (AD) was contacted by phone and the purpose of the visit was discussed.

LPA interviewed five of five clients present at the facility, and three of five clients corroborated that Staff 1 (S1) yells at them. Per clients, yelling consists of S1 elevating their voice to a shout when they make a request, such as requesting medication or entering the kitchen. One of five clients stated S1 “is a ticking time bomb” due to their “short fuse.” LPA also interviewed Witness 1 (W1) who stated they have received multiple reports regarding S1 yelling at clients, from clients themselves and clients’ responsible parties.

Based on interviews conducted, LPA determined staff yells at clients. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. (Cont. LIC9099-C)
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20240827153500
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: 08/30/2024
NARRATIVE
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Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations. (See LIC9099-D).

An exit interview was conducted and copy of this report, and appeal rights were left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240827153500
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2024
Section Cited
CCR
80072(a)
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...each client shall have personal rights which include, but are not limited to, the following:(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature,
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AD stated S1 will be removed and AD stated training will be conducted prior to S1 returning and proof provided via email by POC date.
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This requirement is not met as evidence by:

Based on client and witness interviews, LPA determined that staff yells at clients, which poses an immediate safety and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3