197609092-12-8-2023-31-AS-AALR-CYC5DU-20231208185230

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609092
Report Date: 12/08/2023
Date Signed: 12/08/2023 06:52:57 PM

Document Has Been Signed on 12/08/2023 06:52 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MERCEDES DIAZ HOMES INC - KEYSTONE		FACILITY NUMBER:	197609092
ADMINISTRATOR:	WEBB, MARSHA		FACILITY TYPE:	735
ADDRESS:	2936 N KEYSTONE ST		TELEPHONE:	(562) 945-4576
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	4	CENSUS: 3	DATE:	12/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Home Supervisor, Andrea Munoz		TIME COMPLETED:	07:00 PM

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Licensing Program Analyst (LPA) Antonia Alvizar conducted an Annual Required visit and inspection of the facility. LPA met with Home Supervisor, Andrea Munoz and explained the reason for the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools.

At 4:00 pm, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed throughout the facility. Dual smoke alarms and carbon monoxide detectors are hardwired also tested and function properly. The fire extinguishers are located in the kitchen and garage. The serviced fire extinguisher were dated 02/30/2023.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility properly stored. Knives were stored in a locked cabinet in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Ceiling, floor and walls are in good repair, ample supply of dishes, cups, glasses and utensils for the current resident in care.

Bedrooms: There were four (4) bedrooms designated for clients' use. three of the bedrooms, in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. Hygiene for each resident observed, ample supply of clean linen and storage space.

Bathrooms: There are two (2) bathrooms designated for staff and residents. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 115 degrees Fahrenheit.

Laundry Room: All toxins are stored in a locked cabinet inaccessible to clients in care.

Common Areas: These included the living room, den and dining area. All furnishings are in good repair, lighting is good, walls, ceiling and floors are also in good repair.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MERCEDES DIAZ HOMES INC - KEYSTONE	FACILITY NUMBER: 197609092
	VISIT DATE: 12/08/2023

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Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards. No bodies of water were observed at the facility. There was a shaded patio area with functioning furnisher.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Staff were also interviewed using the CARE Tools questionnaire.
LPA attempted to interview residents but they are non-verbal.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / A Copy of the Report provided to Home Supervisor, Ms. Munoz.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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