306005159-3-20-2025-22-AS-AJLO-DFUMYP-20250418100153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005159
Report Date: 03/20/2025
Date Signed: 03/20/2025 02:36:23 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
01/10/2025 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250110171402

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:	03/20/2025
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Monique Jackson		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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-Facility did not provide care and supervision as necessary to meet the client's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrive at facility was greeted and granted entry by staff.
Findings are based upon this investigation which included resident file review, tour of the physical plant of the facility and interviews conducted.

It is alleged facility did not provide care and supervision as necessary to meet the client’s needs. Interview with 2 of 2 staff stated that client (C1) had a meeting with RCOC service coordinator in November of 2024 that was not scheduled with staff prior. The Facilities protocol with scheduling meeting have to be done prior and with enough time to arrange it, since clients go to day program or work so staff can make sure that clients are home for the meeting. Staff stated they found out on the day of the meeting because one

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

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-20250110171402

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: EMERYWOOD BOARD & CARE HOME	FACILITY NUMBER: 306005159
	VISIT DATE: 03/20/2025

NARRATIVE

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staff arrived for their shift and saw client and RCOC staff in the back patio. Staff (S1) stated that they arrived at the facility for their shift, and it was noted that client and RCOC service coordinator were in the back patio about 5 minutes prior to staff arriving. Staff was informed that RCOC services coordinator scheduled the meeting with C1 in which staff were never made aware of. C1 was at day program and left program early to be able to attend the meeting in which staff was not aware of the details of the meeting or C1 leaving day program till after the meeting. Interview with 4 of 4 clients stated that they get all the assistance they need, staff are always available, and they have no issues with the care they get at the facility.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with facility representative and a copy of this LIC9099 report was left at facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

LIC9099 (FAS) - (06/04)

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