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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609326
Report Date: 07/13/2023
Date Signed: 07/13/2023 04:43:12 PM

Document Has Been Signed on 07/13/2023 04:43 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-BRIGHTONFACILITY NUMBER:
197609326
ADMINISTRATOR:DOMINGUEZ, MICHELLEFACILITY TYPE:
735
ADDRESS:1301 N BRIGHTON STTELEPHONE:
(818) 478-1532
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 4CENSUS: 4DATE:
07/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Direct Support Professional, Raquel NajarroTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Antonia Alvizar conducted a Case Management (CM) visit to to the facility to follow up on an Incident Report received regarding Client #1 (C1) on or around June 17, 2023. LPA met with staff, Jesica Guzman and Russell Smart advised them of the visit. Later, staff Raquel Najarro arrived to the facility. LPA spoke to Administrator, Cecila Loaisiga and Manager, Genesis Zuniga via phone.
At Running Waters Day Program C1 expressed suicide ideation and intent to kill himself.

The purpose of the visit is to insure the health and safety of the client. The day's visit consisted of interviews, gather documentation, and record review. Per review, and based on the information received, it was determined that facility is providing C1 with several consulting support agencies for behavior. It doesn't appear to be that C1 is a danger to self.

No deficiencies observed during the visit.

Exit interview conducted, a copy of the report was issued.




SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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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