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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005159
Report Date: 12/13/2021
Date Signed: 12/13/2021 01:11:20 PM

Document Has Been Signed on 12/13/2021 01:11 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
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: 2DATE:
12/13/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:43 PM
MET WITH:Jeanette SilvaTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 11/18/2021. LPA was greeted and granted entry into the facility by House Manager Jeanette Silva and explained the reason for the visit.

During the visit, LPA observed the following:

*Deficiency cited under Title 22 Regulation 80078(a) pertaining to Care and Supervision has been cleared. Administrator provided proof of correction.. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 80087(a) pertaining to Maintenance and Operation has NOT been cleared. Ceiling in entryway has been repaired but light needs to be fixed/ repaired. Licensee has NOT complied with the terms of the POC. Please repair light by 12/20/2021 to avoid any additional citations/ civil penalties.





Exit interview was conducted and a copy of the report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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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