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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001407
Report Date: 09/14/2022
Date Signed: 09/14/2022 12:55:31 PM

Document Has Been Signed on 09/14/2022 12:55 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 COURTFACILITY NUMBER:
306001407
ADMINISTRATOR:DAIZEL C GASPERIANFACILITY TYPE:
740
ADDRESS:1731 MEDICAL CENTERTELEPHONE:
(714) 778-5100
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 139CENSUS: 258DATE:
09/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Daizel GasperianTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to the facility to verify the capacity and the number of residents residing at the facility. LPA was screened for symptoms of Covid-19 and granted entry. LPA met with Executive Director Daizel Gasperian. LPA explained the reason for the visit. The Executive Director provided the LPA with facility maps showing the layout of all the facility buildings. Executive Director reported there are currently 258 residents at the facility. According to the license and the current fire clearance the capacity of the facility is 139, but the current census of residents is 258. LPA explained to the Executive Director that the facility must request an increase in capacity and obtain a new fire clearance. Executive Director stated she understood. Violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report along with the citation and Appeal Rights was provided to the Executive Director.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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Document Has Been Signed on 09/14/2022 12:55 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 09/14/2022 at 12:16 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 COURT
FACILITY NUMBER: 306001407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2022
Section Cited
CCR
87158(a)

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A license shall be issued for a specific capacity which shall be the maximum number of residents which can be provided care at any given time. The capacity shall be exclusive of any members of the licensee's own family who reside at the facility... This requirement is not being met as evidenced by;
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The Licensee states a new application will be completed requesting an increase in capacity and a new fire clearance will be requested reflecting the correct capacity of residents. Licensee to submit proof application for an increase in capacity to the LPA by the POC due date.
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Through a record review of the fire clearance and facility license and through interviews it has been determined that the facility has 258 residents and the approved fire clearance capacity and facility license is for 139 residents, this poses an immediate health and safety risks to residents.
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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:Luz Adams
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


LIC809 (FAS) - (06/04)
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