<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609092
Report Date: 11/07/2024
Date Signed: 11/07/2024 11:42:48 AM

Document Has Been Signed on 11/07/2024 11:42 AM - 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 - KEYSTONEFACILITY NUMBER:
197609092
ADMINISTRATOR/
DIRECTOR:
WEBB, MARSHAFACILITY TYPE:
735
ADDRESS:2936 N KEYSTONE STTELEPHONE:
(562) 945-4576
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 4CENSUS: 4DATE:
11/07/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Andrea MunozTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 10:10 a.m. on 11/07/24 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the house supervisor and disclosed the reason for the visit.

Today’s case management visit was conducted for a welfare check for all clients in care due to the death of the licensee. LPA interviewed staff and clients between 10:15 a.m. and 11:15 a.m., toured the facility at 10:45 a.m., and conducted a record review of pertinent documents, including but not limited to the staff and client lists, staff schedule, and other client records at 11:10 a.m.

LPA observed sufficient food and water supplies in the facility. All furnishings were safe and sanitary. Two (02) out of four (04) clients were interviewed and observed to be in good health. The house supervisor relayed that the two (02) other clients were at day programs. The house supervisor also confirmed the licensee had recently passed away and all operations have continued as usual. Groceries have been delivered every week, all meals and snacks have been prepared on time, and all staff continue to work as scheduled. The main office is responsible paying bills, utilities, and mortgage. LPA called the main office at 11:30 a.m. to inquire upon plans for continued licensure of the home. LPA was informed that the overseeing corporation will meet with the Monterey Park Adult and Senior Care Regional Office on 11/12/24 to discuss the future plans of all facilities.

At this time all clients and staff in the home are healthy and in good condition, and the facility itself remains safe and in good repair.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1