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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609326
Report Date: 03/11/2022
Date Signed: 03/11/2022 05:01:56 PM

Document Has Been Signed on 03/11/2022 05:01 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MERCEDES DIAZ HOMES INC-BRIGHTONFACILITY NUMBER:
197609326
ADMINISTRATOR:DOMINGUEZ, MICHELLEFACILITY TYPE:
735
ADDRESS:1301 N BRIGHTON STTELEPHONE:
(818) 478-1532
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 4CENSUS: 3DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:48 PM
MET WITH:Administrator Michelle DominguezTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an annual required visit. LPA met with Administrator Michelle Dominguez and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed staff and client files. The facility is licensed to serve four (4) developmentally disabled adults between the ages of 18-59. LPA observed the three (3) residents at the time of this visit.
There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.
LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways are free of obstruction.

The facility consisting of: four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, laundry room, detached garage with an upstairs storage room is located in the rear of the property with entry from the alley, with a patio area in the backyard, an outdoor shaded area. Facility was free of odor. LPA observed sufficient furniture and lighting throughout the facility. Facility has a fire sprinkle system. Smoke and carbon detectors were in good repair. The fire extinguishers observed to be fully charged. The common areas such as living room and dining room are clean and have the required furniture.

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SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MERCEDES DIAZ HOMES INC-BRIGHTON
FACILITY NUMBER: 197609326
VISIT DATE: 03/11/2022
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Client bedrooms were toured. All bedrooms were furnished with required furnitures and have a sufficient closet space. The client bathrooms were toured. Bathrooms have the required hygiene items, grab bars and non-skid mat. The hot water was 108.1 degrees which is within the required 105 - 120 degrees. Cleaning supplies and chemicals are inaccessible to clients.

The kitchen was toured. All appliances were clean and operating properly. There was a sufficient amount of perishable and non-perishable food. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations.

LPA reviewed residents and staff records. Residents' records were found to be complete and current. Staff files were reviewed and documentation noted that facility staff maintain a criminal record clearance and associated to the facility. Medications are documented properly and stored appropriately.

Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit.

A copy of the report was provided to the Administrator.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC809 (FAS) - (06/04)
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