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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803191
Report Date: 06/23/2022
Date Signed: 06/23/2022 11:58:48 AM

Document Has Been Signed on 06/23/2022 11:58 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MERCEDES DIAZ HOMES INC - MAR VISTAFACILITY NUMBER:
197803191
ADMINISTRATOR:NAYELI NOLASCOFACILITY TYPE:
735
ADDRESS:14620 MAR VISTA STTELEPHONE:
(562) 789-3400
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY: 6CENSUS: 6DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Nayeli Nolasco, AdministratorTIME COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA explained the purpose of the visit with DSP Mitzi Beltran. Administrator Nayeli Nolasco arrived shortly after. There are six (6) clients level 4i specialized developmentally disabled clients ages 59 and under. Facility is a one-story home licensed for 6 ambulatory only clients. It is located in a residential area consisting of five (5) client bedrooms, 3 bathrooms, kitchen, dining room, living room, covered patio area, and detached garage with laundry area. The facility has a fire pull alarm system that was tested today. The last emergency disaster drill was completed on May 6, 2022. Administrator certificate expires 12/8/2023.

The following were observed/inspected:
  • COVID-19 Infection Control Practices/screening area was observed in the main entrance. LPA was screened. Infection control signs, and other signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Hand sanitizer was observed.
  • The facility has two private rooms that are designated as COVID-19 isolation rooms if needed.
  • Staff responsible for direct care and supervision were observed wearing a mask.
  • Clients were observed wearing masks in the facility common areas.
  • Sufficient supply of 2 day perishable food & non-perishable foods for 7 days were observed.
  • A Emergency Disaster Plan was posted.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Three (3) centrally stored medication records were reviewed.
  • Staff (S1) was not cleared or associated to the facility.

***A deficiency was cited and civil penalty was assessed.
Exit interview was conducted with Administrator Nayeli Nolasco. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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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Document Has Been Signed on 06/23/2022 11:58 AM - It Cannot Be Edited


Created By: Noemi Galarza On 06/23/2022 at 11:34 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERCEDES DIAZ HOMES INC - MAR VISTA
FACILITY NUMBER: 197803191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff (S1) began working at the facility in February 2021 without clearance; which poses an immediate health, safety or personal rights risk to persons in care.The Caregiver Background Check Bureau sent licensee correspondence in June 2021 stating staff (S1's) application was incomplete. However, CBCB did not receive a response.
POC Due Date: 06/24/2022
Plan of Correction
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Licensee shall submit proof that a clearance request was submitted to CBCB for staff (S1). Staff cannot return to work at licensed facilities until it has received criminal record clearance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022


LIC809 (FAS) - (06/04)
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