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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006187
Report Date: 12/16/2024
Date Signed: 12/16/2024 02:50:35 PM

Document Has Been Signed on 12/16/2024 02:50 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:EMERALD GUEST HOMEFACILITY NUMBER:
306006187
ADMINISTRATOR/
DIRECTOR:
CADIZ, FERNANDOFACILITY TYPE:
735
ADDRESS:3426 W GLEN HOLLY DRIVETELEPHONE:
(714) 527-6084
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 3DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Imelda Cadiz - LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:06 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by facility staff. Licensee Imelda Cadiz arrived to the facility approximately 90 minutes after LPAs arrival. LPA explained the purpose of the inspection.

The facility is one-story building with 4 client rooms, 2 client bathroom, kitchen, dining room, living room, staff room, staff bathroom, backyard and 2-car garage. All client rooms had the required elements, including bed, chair, closet space and ample lighting. LPA observed the facility to be in good repair. LPA observed two exit gates that are self-latching and unlocked. Facility has toxins, chemicals and cleaning supplies locked in the garage and under the sink in the kitchen. LPA observed sharps to be locked in a cabinet in the kitchen. Restrooms are stocked with soap and paper towels. LPA observed facility has emergency food and water supply as well as additional emergency supplies. LPA observed the fire extinguishers are full as indicated by the meter on them. LPA observed the service tags on the extinguishers stating they were serviced on 5/14/24. Smoke and Carbon Monoxide detectors tested operational. Appliances tested operational. LPA reviewed 6 staff files and all 3 client files. LPA reviewed the P&I and medication for all clients. LPA conducted interviews with two staff and one client. All other clients were away at Day Program.



Based on today's inspection, no deficiencies are being issued. An exit interview was conducted and a copy of this report, deficiency pages and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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