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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006187
Report Date: 11/17/2022
Date Signed: 11/17/2022 11:29:50 AM

Document Has Been Signed on 11/17/2022 11:29 AM - 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:EMERALD GUEST HOMEFACILITY NUMBER:
306006187
ADMINISTRATOR:CADIZ, IMELDA B.FACILITY TYPE:
735
ADDRESS:3426 W GLEN HOLLY DRIVETELEPHONE:
(714) 527-6084
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 1DATE:
11/17/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Imelda CadizTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and was greeted and granted entry by designated Administrator (AD) Imelda Cadiz. An application to operate an Adult Residential Facility (ARF) for (6) capacity, (6) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 5/10/2022.

Structure:
The facility is a one-story home with 3 client bedrooms, 1 staff bedroom, 1 client bathroom, 1 staff bathroom, living room, kitchen, and an attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room area. There is a back yard with two exit gates on each side of the house. There is a shaded seating area in the backyard. No bodies of water observed. LPA did not observe any obstacles or hazards in the backyard.

Client Bedrooms
All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened.

Signal system
There is no signal system.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in a kitchen cabinet.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: EMERALD GUEST HOME
FACILITY NUMBER: 306006187
VISIT DATE: 11/17/2022
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Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kit is stored with the medication. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in the kitchen.

Pool/Jacuzzi:
No bodies of water in facility.

Fire Extinguisher:
All fire extinguishers observed are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has magazines, crayons, coloring books, and board games kept in the living room.

Fire clearance:
Was approved by a fire inspector of the Anaheim Fire Department on 09/26/2022. No special conditions noted.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:


One staff bedroom, two staff will be living at the facility.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 130.4 degrees Fahrenheit.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: EMERALD GUEST HOME
FACILITY NUMBER: 306006187
VISIT DATE: 11/17/2022
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Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas five burner stove with 1 oven, 3 refrigerators, dish washer, microwave, washer, and dryer are operational.

Licensee to address the following corrections by 11/30/2022:

  • Water temperature is out of compliance in the following rooms, one out of one client bathrooms.

The facility is not ready to be licensed. Licensee to contact LPA when corrections are complete.

An exit interview was conducted with Licensee and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3