197609092-2-20-2025-31-AS-NSHN-DE3USH-20250220145023

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609092
Report Date: 02/20/2025
Date Signed: 02/20/2025 02:51:53 PM

Document Has Been Signed on 02/20/2025 02:51 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MERCEDES DIAZ HOMES INC - KEYSTONE		FACILITY NUMBER:	197609092
ADMINISTRATOR/ DIRECTOR:	WEBB, MARSHA		FACILITY TYPE:	735
ADDRESS:	2936 N KEYSTONE ST		TELEPHONE:	(562) 945-4576
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY: 4		CENSUS:	DATE:	02/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Octavio Torres-Rodriguez / Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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	Licensing Program Analyst (LPA) Nadia Shahbazian and Licensing Program Manager (LPM) Eva Miller conducted an unannounced Required - 1 Year annual inspection visit. Upon their arrival, staff on duty were, House Supervisor Andrea Munoz and Direct Care Staff/Robert Martinez, Alicia Ramirez, Eduardo De La Cruz. LPA explained the purpose of the visit. Administrator Octavio Torres-Rodriguez arrived at 10:30am. The program is vendorized through the Frank D. Lanterman Regional Center. The Adult Residential Facility is licensed for 4 ambulatory adults, ages 18 through 59, one of whom may be non-ambulatory. Current census is four (4) residents. LPA/LPM toured the facility with the House Supervisor at 9:30 am and observed the following: Required postings were observed in the kitchen, garage and entry area. The front entry is the main exit door and the secondary exit door leads to the backyard. The physical plant appeared clean, sanitary and comfortable with no visible immediate hazards. There are two fire extinguishers, one in the kitchen, one in the garage. The fire extinguisher in the kitchen was fully charged on 02/11/2025 and the one in garage was charged on 02/23/2024. Facility conducts monthly fire and safety drills, the last fire drill was conducted on 02/03/25. In addition, a facility inspection was conducted by the Burbank Fire Department on 02/03/2025. Kitchen: The kitchen appliances consisted of a refrigerator, stove, dishwasher and microwave and the fixtures were observed to be functional. Knives, cutlery (Continued on 809C)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: MERCEDES DIAZ HOMES INC - KEYSTONE	FACILITY NUMBER: 197609092
	VISIT DATE: 02/20/2025

NARRATIVE

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and sharp kitchen objects are stored in locked kitchen cabinets. The cleaning supplies were also locked in cabinet underneath the sink. LPAs found a sufficient supply of perishable foods (2 days) and non-perishable food (7 days) supplies, with sufficient amount of dishes for the census of four (4).

Bathrooms: There are two (2) bathrooms designated for staff and residents’ use. All toilets and sinks are maintained in sanitary, operating condition. LPA/LPM observed proper grab bars and non-skid mats in both bathrooms. Hot water temperature was measured at 117 and 114.4 degrees Fahrenheit.

Bedrooms: There are four (4) private bedrooms designated for clients' use. All of the bedrooms were properly furnished with appropriate chairs, beddings. television sets, linens with sufficient lighting.

Laundry Room: Laundry machines were located near the entry door. All toxins are stored in a locked cabinet inaccessible to clients in care.

First-Aid Kit: There are three complete first-aid kits on in the kitchen with all required supplies and the first aid manual.

Common Areas: Include a den, living room and two (2) dining areas. The common areas were properly furnished with ample sitting/tables for appropriate number of clients. Television set and activity/gaming areas were observed in the living room. Exterior security cameras were installed in the front and rear entries. The dual smoke alarms and carbon monoxide detectors are hardwired and interconnected. At 9:49 am the smoke/carbon monoxide alarms were tested and observed to function properly.

(Continued on 809C)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MERCEDES DIAZ HOMES INC - KEYSTONE	FACILITY NUMBER: 197609092
	VISIT DATE: 02/20/2025

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Surrounding grounds: Entry/exit gates and pathways were free of obstruction. The outdoor area was free of visible immediate hazards. No bodies of water were observed at the facility. There is ample patio space for outdoor activities. There was a shaded patio area with furniture appropriate for outdoor use sufficient for all clients.

At 12:00pm, LPA & LPM initiated a review of facility Staff and Client files.

Resident Files: A review of resident records to ensure compliance of licensing forms was conducted. Medications records for residents were also verified for accuracy of administration based on physician orders.

Staff Files: Staff files were reviewed to ensure all forms and training certificates are up to date.

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 Administrator, Octavio Torres-Rodriguez.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

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