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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006187
Report Date: 12/05/2023
Date Signed: 12/05/2023 03:43:35 PM

Document Has Been Signed on 12/05/2023 03:43 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: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: 4DATE:
12/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Manny LubayTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Manny Lubay. LPA discussed the purpose of the inspection and Administrator (AD) Fernando Cadiz was contacted by phone and arrived at 3:00 p.m.

During the inspection LPA and Staff Lubay conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with four bedrooms, two bathrooms, and attached two-car garage. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The back yard has a shaded sitting area. LPA observed two clients present, as all other clients were away at day program. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 107.2 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Stove burners, microwave, washer, and dryer were all inspected. Sharps were observed locked in a detached cabinet in the kitchen. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to locked. LPA reviewed four client files and no staff files as they were not accessible; a deficiency was cited on today's date. LPA interviewed staff and a deficiency was cited on today's date. LPA also interviewed clients present.

Based on the observations made during today’s inspection, three deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was 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: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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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Document Has Been Signed on 12/05/2023 03:43 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 12/05/2023 at 02:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EMERALD GUEST HOME
FACILITY NUMBER: 306006187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(e)
The Administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on AD admission, the licensee did not comply with the section cited above as AD stated they do not do paper work for the facility and was unable to access locked file cabinet containing clients' physician reports and personnel files which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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AD stated they would review responsibilities with Licensee to ensure they are able to manage and administer facility, and are able to access records upon request. AD will provide LPA with a copy of AD training conducted via email by POC date.
Type B
Section Cited
HSC
1565(c)
A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenerios.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as a disaster drill has not been conducted at the facility since December 2022, which poses a potential health and safety risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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AD stated they would conduct a disaster drill today and will continue conducting them quarterly as required by regulation. AD will provide LPA with a copy of disaster drill log via email by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/05/2023 03:43 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 12/05/2023 at 03:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EMERALD GUEST HOME
FACILITY NUMBER: 306006187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(12)(B)
Documentation of either a criminal record or exemption as required by Section 80019(d)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as AD was unable to provide documentation of criminal background clearance or exemption for two out of two staff present, which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 12/06/2023
Plan of Correction
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AD stated they have a copy of criminal background clearnace for both staff but are not able to access documentation. AD stated they will provide LPA with a copy of criminal background clearance via email by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023


LIC809 (FAS) - (06/04)
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