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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202539
Report Date: 10/10/2025
Date Signed: 10/10/2025 01:08:35 PM

Document Has Been Signed on 10/10/2025 01:08 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:EMERALD ISLE ASSISTED LIVING IIIFACILITY NUMBER:
198202539
ADMINISTRATOR/
DIRECTOR:		LINDSEY NETTINGERFACILITY TYPE:
740
ADDRESS:27781 HAWTHORNE BLVDTELEPHONE:
(310) 544-3308
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 5DATE:
10/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Ceceni Rose - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:16 PM
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On 10/10/25 at around 9:20AM, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Required – 1 Year Inspection at the facility and met by staff one, Ceceni Rose - Administrator (S1) and the purpose of the visit was explained.
The facility is a one-story house located in a residential area. The home consists of four (4) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, a kitchen and a dining/living room area, with a backyard patio with shaded seating; including a fully gated swimming pool. The facility currently hosts five (5) residents; including four (4) residents receiving hospice care, although this facilities' license allows for one (1) resident receiving hospice. One technical violation has been cited, please see LIC9102TV.
LPA toured the facility, inside and out, with staff two, Maricar "Lea" Avendano (S2). LPA observed, and questioned, no security bars or weapons on the premises. LPA toured the kitchen area and observed supplies of 7 days of nonperishable foods and 2 days perishable food for residents in care. Knives and toxins were kept in locked storage cabinet, inaccessible to residents in care and all heating sources are secured and screened.
LPA observed that medications were secured and inaccessible to residents in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated, located behind the fireplace island. First aid kit is fully stocked, along with manual. Smoke and carbon monoxide detectors were in compliance and operational. There is a fire extinguisher in the kitchen, last serviced on 09/08/2025. Four (4) out of 5 bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. LPA observed cobwebs in bedroom one's (BR1) lamp. LPA observed two light switches needing minor repair, yet are still in working order. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and non-skid mats were in place. Adequate lighting and toiletries are accessible to residents in care.
The report continues, please see LIC809C.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: EMERALD ISLE ASSISTED LIVING III
FACILITY NUMBER: 198202539
VISIT DATE: 10/10/2025
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LPA tested hot water temperature and the average temperature was calculated at 106.1°F (degrees Fahrenheit) throughout the facility. This facility provides residents with hygiene products such as feminine napkins, non-medicated soap, toilet paper, toothbrush, toothpaste, and comb.

During today's visit, there have been zero (0) deficiencies cited.
There has been one (1) technical assistance note provided, please see LIC9102TA. There has been one (1) technical violation note provided, please see LIC9102TV.

An exit interview was held with staff one, Ceceni Rose - Administrator (S1), and a copy of this report and LIC9102TA and LIC9102TV have been provided.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC809 (FAS) - (06/04)
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