Emerald Isle Assisted Living III

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Oct 10, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

This document is amended to update the number of approved bedridden residents. On 09/14/2024 at around 9:40 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Licensee Assistant Cecenirose Pare. LPA explained the purpose of the visit and was accompanied by staff inside and outside the facility during this inspection. This facility is licensed to serve 6 bedridden residents ages 60 and above. Complaint with 87705 - Care of Persons with Dementia. Approved for 1 Hospice resident at any given time. There are a total of 5 residents residing in this facility. There are a total of 2 hospice residents residing in this facility. There are a total of 1 bedridden resident in this facility. The facility is a one-story house located in a residential street. The home consists of 4 resident bedrooms, 1 staff bedroom, 3 bathrooms, 1 kitchen, 1 dining/living room area, 1 backyard swimming pool, 1 attached garage,1 backyard patio area with shaded seating. The patio furniture is under a shaded area and accessible to residents. There are no security bars or weapons on the premises. There is construction currently happening in the facility. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet. LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There is a fire extinguisher in the kitchen and it was last serviced on 09/05/2024. 5 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. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb. 5 staff records were reviewed, 3 out of 5 staff records had required documentation. 2 out 5 staff files were incomplete. 5 resident records were reviewed and, 5 out of 5 resident records had required documentation. A technical assistance is being issued for: videoconferencing devices dedicated for client use, maintaining complete files in the facility, and facility construction or alterations. LPA explained to Licensee Assistant to contact their designated LPA Leon and inform them of their construction plan. Email: Mario.Leon@dss.ca.gov Deficiencies are being cited based on LPA observation, record review and interviews conducted in accordance with the California Code of Regulations, Title 22. Violation regarding: Hospice Waiver, Fire Clearance for Bedridden Residents, and Complete & Current Medication Administration Records (MAR). An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Licensee Assistant.the state’s words, verbatim · CDSS document, Sep 14, 2024

Allegation investigated: Resident sustained a fracture while in care Resident sustained multiple falls while in care Staff did not properly report an incident involving a resident Staff did not follow a resident's needs and care plans Facility has inadequate record keeping

On (03/14/2024), Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced subsequent visit to Emerald Isle Assisted Living III. LPA conducted a risk assessment prior to entering the facility. LPA was greeted by Administrator (A1) Laura Martz and LPA explained the purpose for today’s visit is to investigate the above-mentioned allegations and deliver the findings. The investigation consisted of the following: An initial visit was conducted on 11/01/21 around 09:00AM by LPA Calderon with Administrator Martz for health & safety purposes of residents in care. During this visit, LPA conducted a physical plant tour which included five (5) bedrooms, two (2) bathrooms, plus all common areas that included the kitchen, dining room, and living room. LPA observed two (2) cameras in the dining room and living room areas. LPA Calderon requested a copy of Resident #1’s file, facility staff and residents’ rosters, staff training records, incident report (dated 10/19/21), Administrator file, facility’s plan of operation, and video footage of incident (dated 10/19/21). The complaint investigation was referred to the California Department of Social Services Investigation Branch and was assigned to Investigator Christine Ferris which included a review of medical records (dated 10/19/21 – 10/22/21) from Torrance Memorial Medical Center; interviews of former and current facility staff, residents in care, and witnesses; observation of facility’s video recording (between 16:39:07 hours – 16:41:32 hours). Unsubstantiated LPA Calderon conducted a subsequent visit on 05/22/23 at 08:45AM and was greeted by Staff #1 (S1: Sarah Reyes, Caregiver). During this visit, LPA Calderon toured the facility to include all common areas. LPA interviewed staff (S1-S3) and witnesses (W1-W6) and attempted interviews with residents (R2-R4). During this investigation, LPA Calderon interviewed Residents (R1-R3), Administrator (A1), and Staff (S1-S3). LPA Calderon obtained and reviewed the following documents: Appraisal/Needs and Services Plan (dated 12/14/19), Physician’s Report (dated 12/14/19), Admission Agreement (dated 12/14/19), video footage (dated 12/20/20), hospital records (dated 11/05/21), photographs of Resident #1 (dated 10/19/21). LPA also reviewed the Department’s Investigation Branch (IB) report from Investigator Chrisine Ferris. The investigation revealed the following: Allegation #1: Resident sustained a fracture while in care. This complaint alleged that resident sustained a fracture while in care from a fall. Resident #1 was admitted to Torrance Memorial Medical Center on 10/19/21 due to a fall observed (via) facility’s video recording. On 04/30/22, further review of R1’s medical records documented that the resident was experiencing health issues and x-rays done for the resident did not suggest any fracture was found. During the investigation, there were no reports of neglect or lack of supervision. On 01/10/23, LPA Calderon interviewed Administrator Martz. The administrator’s written statement (dated 11/01/2021) stated that Resident #1 sustained an unwitnessed fall based on the facility’s video recording. Administrator stated that R1 was sitting in a recliner chair, stood up, lost their balance, and fell to the floor. Staff #1 rushed to R1’s aid and assisted the resident off the living room floor. The Department’s Investigation Branch, Investigator Chrisine Ferris, found there was no evidence to corroborate the above-mentioned allegation. The information and evidence obtained did not sufficiently support the allegation. Allegation #2: Resident sustained multiple falls while in care. This complaint alleged that resident sustained multiple falls while in care. Resident #1 did not have 1:1 care and reportedly did not have a significant history of falls. On 10/19/21, the caregivers on duty at the time of R1’s fall were preparing dinner within (approximately) 40 feet of where R1 was sitting prior to the fall. The facility’s video recording captured R1’s fall and the caregivers’ response time to be within an appropriate timeframe and providing the medical assistance including calling 9-1-1. Resident #1 was taken to Torrance Memorial Medical Center for a right fracture of the hip. Medical report does support a non-displaced fracture of the right femoral neck. A review of the hospital medical records on 04/30/22 does not support multiple falls while in care. On 01/10/23, LPA Calderon reviewed a written statement (dated 11/1/2021) from A1. The administrator stated that Resident #1 did not sustain multiple falls while in care; and that facility staff provided care to R1 after the fall happened on 10/19/21. On 10/29/22, LPA Calderon reviewed the video recording which suggested that R1 was in recliner chair, stood up, lost their balance, and fell to the floor. The video suggested that Staff #1 assisted R1 within seconds of R1 falling from the recliner chair. On 05/22/23, LPA Calderon interviewed staff (S1-S3). Staff #1 stated that if a resident fell, all staff would aid the resident’s medical needs. Staff #2 stated that it is rare for a resident to fall; but, if this does happen, facility staff will provide medical aid including calling 9-1-1 or taking a resident to the hospital, if needed. 2 of staff interviewed by IB Investigator Ferris denied R1 sustaining multiple falls in care. IB investigator conducted a review of R1 file and did not observe any documentation that R1 sustained multiple falls while in care. The Department’s Investigation Branch, Investigator Chrisine Ferris, found there was no evidence to corroborate the above-mentioned allegation. The information and evidence obtained did not sufficiently support the allegation. Allegation #3: Staff did not properly report incident involving resident.This complaint alleged that staff did not properly report an incident involving a resident. On 10/29/22, LPA Calderon interviewed A1. A1 states that R1 lost balance and fell to the floor. A1 states that staff reported the fall to A1 and then called R1 family to advise of the fall. A1 states that A1 filed an incident report and reported the loss to DSS as required. A1 states that there was video of the fall and A1 allowed R1 family to view the video for transparency. On 10/29/22, LPA Calderon reviewed A1 written statement for complaint. A1 provided a copy of A1 written statement to R1 family for their review. On 05/22/22, LPA Calderon interviewed staff (S1-S3) for complaints. 3 of 3 staff interviewed denied the allegation and all stated they report incidents. On 05/23/23, LPA Calderon attempted to interview residents (R2-R4) for complaint. Residents could not answer any questions regarding the complaint allegation due to communication barriers. LPA Calderon conducted a file review and noted the Administrator submitted an incident report to Community Care Licensing. Allegation #4: Staff did not follow a resident needs and care plan. This complaint alleged that staff did not follow a resident needs and care plan. On 10/29/22, LPA Calderon interviewed A1. A1 states that staff take care of residents’ needs. A1 states that prior to entering A1 facility all residents must have a needs and service plan. A1 states that all staff must review and follow all resident needs and service plan. A1 states that all staff reviewed R1 needs and Service plan while in their care. On 10/29/22, LPA Calderon reviewed R1 needs and service plan R1 needs, and service plan suggest R1 has balance issues and health issues. On 10/25/22, LPA Calderon received and reviewed the department’s Investigation Branch (IB) Investigator name report. The investigator’s report states: The investigator spoke to staff and all staff followed R1 needs and service plan for R1 care. On 05/22/23, LPA Calderon interviewed staff (S1-S3). 3 of 3 staff denied the allegation. S1 states that S1 is required to review all residents needs and service plan prior to providing care. S1 states that S1 cannot provide the best care possible without knowing what the medical needs for R1 are. S2 states that S2 reviews all medical reports to include the needs and service plan for each resident. S2 states that S2 provides great service by understanding what the medical issues are for each resident. S3 states that the needs and service plan is required reading for each resident. S3 states that S3 provides better care by understanding what each residents’ needs are. On 05/22/23, LPA Calderon attempted to interview residents (R2-R4) for complaint. Due to communication barriers residents could not answer any questions regarding the complaint. LPA conducted a review of R1 Care plan and did not note any discrepancies between the care staff stated they provide. 03/13/24 Allegation #5: Facility has inadequate record keeping. This complaint alleged that the facility has inadequate record keeping. On 10/29/22, LPA Calderon interviewed A1. A1 states that A1 staff keep adequate records on all care provided to residents in A1 care. A1 states that accurate records are kept for R1 to include all medical records and incident reports. A1 states that A1 staff are mandated to keep accurate records on all residents and that all resident’s family can obtain and review all records for their family member. On 10/29/2022 LPA Calderon reviewed the incident report (dated 10/19/2021). Incident Report stated that R1 was sitting in a recliner chair, lost their balance and fell to the floor. Staff called 9-1-1 and R1’s family to advise of the resident’s fall. On 10/29/22, LPA Calderon reviewed the facility’s video recording of R1’s fall. Facility took a video of the living room area. Video recording shows R1 sitting in a recliner chair. The video recording showed R1 trying to get out of their recliner chair, lost their balance, fell to the floor, and within seconds, facility staff came to R1’s aid. The administrator stated that A1 supplied a copy of video recording to R1’s family. The administrator stated that all facility staff follow and keep accurate records and staff take continuous training in record keeping. The administrator stated that all emails are kept and tracked for resident records. On 05/22/23, LPA Calderon interviewed staff (S1-S3). 3 of 3 staff denied the allegation. Staff #1 stated that they are trained to keep records for all resident’s care. Staff #2 stated that they are mandated to keep accurate records for each resident in S2’s care. Staff #33 states that A1 trains all staff to keep records of all care provided by staff to include any hospice records or hospital records. Staff #3 stated that these records can be reviewed by the resident’s family and the records must be accurate. On 05/22/23, LPA Calderon attempted to interview residents (R2-R4) for complaint. Due to health issues, R2-R4 could not answer questions regarding the complaint. Based on the evidence gathered and interviews conducted and records reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations: “resident sustained a fracture while in care” “resident sustained multiple falls while in care” “staff did not properly report an incident involving a resident” “staff did not follow a residents needs and care plan” “ facility has inadequate record keeping” are UNSUBSTANTIATED. A face-to-face interview was conducted with Administrator Laura Martz and a hard copy of the Complaint Report was provided by hand for facility records.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 11-AS-20211029141335

Type of visit: Required - 1 Year

On 11/11/2023 at 9:03 am Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection. LPA was met by Sarah Maria Reyes, caregiver and the purpose of today’s visit was explained. During the visit, LPA observed the facility infection control practices. There are currently three (3) residents in the facility. There are three (3) residents are non-ambulatory, and (2) bedridden. The facility is a single-story structure located in a residential neighborhood. The Residential Care Facilities for the Elderly (RCFE) is licensed to serve (6) bedridden clients age 60 and above, may retain (1) hospice client at any given time. The facility consists of five (5) bedrooms, two (2) full bathrooms, shaded back yard, front yard, pool with gate, laundry room and a detached two (2) car garage. LPA and Sarah Maria Reyes toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1, 2 and 3 are occupied by residents and contain the mandated furniture. Bedroom 7 is a staff bedroom. The three and half (3 1/2) bathrooms have grab bars and non-skid mats and are clean and operational. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detectors were in compliance and operational. No firearms are stored at facility and body of water present (pool with gate.) Medications are stored, locked and inaccessible to residents. Resident files along with medications are current. Staff files are current. Ample supply of perishable and nonperishable food, hot water temperature is (116.6) degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (1) fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. Emergency contacts updated and posted; PPE's are enough for 30 days. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time. Technical Advisory (TA) issued. Resident Rights/Information - Technical Violation: 87468(c)(2)(A) An exit interview conducted with Cecenirose Pare, Caregiver and a hard copy of report was providedthe state’s words, verbatim · CDSS document, Nov 11, 2023

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.