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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609326
Report Date: 06/17/2023
Date Signed: 06/17/2023 02:44:39 PM

Document Has Been Signed on 06/17/2023 02:44 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
Lookup Error,
, CA
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: 4DATE:
06/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Cecilia Loaisiga-AdministratorTIME COMPLETED:
02:44 PM
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On 6/17/2023 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Cecilia Loaisiga/Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for (4) developmentally disabled or Mentally Ill adults ages 18 through 59;(1) non-ambulatory and (3) ambulatory clients. Currently, the home has (4) ambulatory and (0) non-ambulatory client. The clients are from: Lanterman Regional Center. (2) clients have Restricted Health Care Conditions, and (0) are utilizing postural supports or protective devices.

The facility consisting of (4) bedrooms, (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.

LPA Iniguez and DSP toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees (Kitchen 112.9F°, Bathroom #1 116.6°F., Bathroom #2 115.8F°).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2023
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
Lookup Error,
, CA
FACILITY NAME: MERCEDES DIAZ HOMES INC-BRIGHTON
FACILITY NUMBER: 197609326
VISIT DATE: 06/17/2023
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide/Smoke detectors combo were observed and operational. Fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Last facility fire drill was 5/14/2023.

LPA conducted a records review of (2) client records, (3) staff records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (2) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.



An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the Administrator/Cecilia Loasiga.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023
LIC809 (FAS) - (06/04)
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