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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609326
Report Date: 11/07/2024
Date Signed: 11/07/2024 11:38:54 AM

Document Has Been Signed on 11/07/2024 11:38 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MERCEDES DIAZ HOMES INC-BRIGHTONFACILITY NUMBER:
197609326
ADMINISTRATOR/
DIRECTOR:		DOMINGUEZ, MICHELLEFACILITY TYPE:
735
ADDRESS:1301 N BRIGHTON STTELEPHONE:
(818) 478-1532
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 4CENSUS: 4DATE:
11/07/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Genesis Zuniga, the House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina made an unannounced case management visit to this facility. LPA rang the bell and no one answered. Genesis Zuniga, the House Manager, arrived shortly after and LPA explained the reason for this visit.

Licensing was notified that the licensee of the facility had passed away. LPA conducted a walkthrough of the facility. LPA observed one client to be in their rooms watching television. The House Manager informed LPA that three (3) clients are currently at a Day Program. LPA observed there to be a sufficient amount of food available for the clients. No health and safety concerns noted at this time.

LPA also obtained the following information, during today’s visit:

· Census
· Resident Roster
· LIC 500
· Staff Schedule
· Administrator contact information

LPA was also informed that the rent/mortgage, utilities, etc. will have no changes/interruptions. Interview with the Chief Executive Officer (CEO) revealed that an emergency meeting had been scheduled with Monterey Park Regional Office regarding this matter on 11/12/2024 at 12:00pm.

Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
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)
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