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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006187
Report Date: 12/02/2022
Date Signed: 12/02/2022 09:24:47 AM

Document Has Been Signed on 12/02/2022 09:24 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:
12/02/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Imelda CadizTIME COMPLETED:
09:50 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 visit to follow up on corrections identified during visit on 11/17/2022. 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.

At 9:00 a.m., LPA toured the facility and observed the following:

Water temperature in one out of one client bathrooms tested at 130.4 degrees Fahrenheit. Documented temperature from this morning was 106.1 degrees Fahrenheit.

All noted items from visit on 11/17/2022 have been addressed.

The facility is ready to be licensed.

Exit interview conducted 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: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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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