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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202539
Report Date: 08/22/2022
Date Signed: 08/22/2022 04:06:09 PM

Document Has Been Signed on 08/22/2022 04:06 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:EMERALD ISLE ASSISTED LIVING IIIFACILITY NUMBER:
198202539
ADMINISTRATOR:LINDSEY NETTINGERFACILITY TYPE:
740
ADDRESS:27781 HAWTHORNE BLVDTELEPHONE:
(310) 544-3308
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 4DATE:
08/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Paul Lawrence Dizon, AdministratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) conducted a case management visit to the above facility. LPA was met by Paul Dizon, Administrator and the purpose of the visit was explained.

Licensee Laura Martz, reported on 08/22/22, a car accident that affected the facility above. A car came driving down on Gracelake Ave coming down the hill and drove through major street Hawthorne blvd and a cult de sac and hit the facilities outside brick wall. Then car kept going and hit the side of the garage and still kept going and hit another brick potted bed flower which was in front of home. The fire department and building and safety came to access damage and Reg Tagged the facility. They are not allowed to enter or occupy the residence. There are 4 non-ambulatory residents in the facility. 3 male 1 female, 2 are on hospice and hospice is working on transferring services for them to new placement. Hospice is St. Arsenius. All 4 resident will be moved to Emerald Isle Assisted living 2 #198201753 which has a capacity of 6 and current census is 5. 2 of the resident families are helping the facility to move their resident. The other 2 residents are being moved by Hospice.

An exit interview was conducted with Paul Dizon, Administrator and copy of report provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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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