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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006187
Report Date: 09/27/2025
Date Signed: 09/27/2025 12:45:29 PM

Substantiated


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
05/18/2023 and conducted by Evaluator Samer Haddadin
COMPLAINT CONTROL NUMBER: 22-AS-20230518151006
FACILITY NAME:EMERALD GUEST HOMEFACILITY NUMBER:
306006187
ADMINISTRATOR:CADIZ, FERNANDOFACILITY TYPE:
735
ADDRESS:3426 W GLEN HOLLY DRIVETELEPHONE:
(714) 527-6084
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 3DATE:
09/27/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Nataly AvilaTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Facility not able to meet client's needs
Staff did not obtain medical care for the client in a timely manner
Facility does not have sufficient staffing to assist client off the floor
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint visit to the facility to present findings regarding the above-referenced allegations. The investigation addressed three allegations: “Facility not able to meet client’s needs,” “Staff did not obtain medical care for the client in a timely manner,” and “Facility does not have sufficient staffing to assist client off the floor.” Upon arrival, LPA Haddadin was greeted by care staff and granted entry. The investigative process included a facility tour, interviews with three staff members and two clients, and a review of records pertinent to the allegations.
The investigation revealed that Client 1 (C1) had been asked by Staff 1 (S1) to assist Client 2 (C2) off the floor following a fall, as S1 reported being unable to lift due to a back injury. All three staff interviewed corroborated that C1 was asked to help lift C2, and both clients interviewed stated they had also been asked by S1 on separate occasions to assist C2 after a fall.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2025
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 4
Control Number 22-AS-20230518151006
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: EMERALD GUEST HOME
FACILITY NUMBER: 306006187
VISIT DATE: 09/27/2025
NARRATIVE
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 C1’s responsible party reported the belief that C2 required a higher level of care than the facility could provide. A review of C2’s physician’s report confirmed that C2 had a seizure disorder, required assistance with ambulation, and was unable to care for personal needs.
In an interview with the licensee, the licensee acknowledged that C2 required a higher level of care and admitted being aware that C1 had been asked to assist staff in lifting C2 from the floor. The licensee further admitted that during the incidents, S1 was the only staff on duty and was limited by a back injury. The licensee also confirmed that medical attention was not obtained at the time of C2’s falls, and instead, other clients were enlisted to assist.
Based on the preponderance of the evidence, all three allegations were substantiated. The allegation “Facility does not have sufficient staffing to assist client off the floor” was substantiated as interviews and the licensee’s statements established that only one staff member was on duty, who was unable to perform required lifting and instead relied on clients to perform staff duties. This resulted in delayed or inadequate assistance when C2 was on the floor. The allegation “Staff did not obtain medical care for the client in a timely manner” was substantiated as interviews and licensee admissions confirmed that no medical evaluation was sought following C2’s falls despite the client’s identified medical conditions and needs, thereby placing the client at potential risk of harm. The allegation “Facility not able to meet client’s needs” was substantiated as C1 and other clients were asked by S1 to lift C2 from the floor as well as C2’s physician’s report documented care requirements beyond the facility’s capabilities, and the licensee admitted retaining C2 despite knowing a higher level of care was needed.
The preponderance of evidence standard has been met; therefore, the allegations are SUBSTANTIATED. Violations are being cited under California Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report along with appeal rights was provided to the licensee.

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20230518151006
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: EMERALD GUEST HOME
FACILITY NUMBER: 306006187
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2025
Section Cited
CCR
85065(b)
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85065(b)“The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.” Based on staff and client interviews, the facility did not employ sufficient staff to meet the immediate needs of clients.
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. The licensee will submit to Community Care Licensing, by Due date a written staffing plan that demonstrates sufficient coverage for all shifts.
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 Specifically, Client 1 (C1) was asked by staff to assist in lifting C2 who had fallen. Staff reported that due to a back injury, they were unable to provide the required assistance on their own, resulting in C1 being involved in lifting the resident. This posed a potential health and safety risk to clients in care.
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Documentation of staff training on proper lifting techniques, client safety, and emergency response procedures shall also be provided.
Type B
10/11/2025
Section Cited
CCR
80075(a)
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80075(a)"The licensee shall ensure each client receives first aid and other needed medical or dental services..." Based on record review, staff and client interviews, the facility did not obtain
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The licensee shall submit to Community Care Licensing by Due datw: 1) a written protocol detailing staff steps for obtaining urgent and non-urgent medical care and arranging transportation;
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 medical care for Client 2 (C2) in a timely manner. Instead, facility staff asked C1 to help C2 off the floor which posed a potential health and safety risk to clients in care
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2) proof of staff training on recognition of urgent symptoms and emergency response; and 3) documentation showing the protocol has been incorporated into the Plan of Operation.
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: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20230518151006
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: EMERALD GUEST HOME
FACILITY NUMBER: 306006187
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2025
Section Cited
CCR
85068.2(a)
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85068.2(a)Prior to admission, the licensee shall determine whether the facility’s program can meet the prospective client’s service needs and shall complete a written Needs and Services Plan specifying the services to be provided.
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The licensee shall complete and submit to Community Care Licensing by due date proof of a file audit for all current clients verifying that each has a current Needs and Services Plan consistent with assessed needs.
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Based on record review and interviews and licensee’s admission, Client 2 (C2) required a higher level of care than the facility provides. This failure posed a potential health and safety risk to clients in care.
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 The licensee shall also provide documentation of staff training on admission assessment procedures and development, implementation, and review of Needs and Services Plans.
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2025
LIC9099 (FAS) - (06/04)
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