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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803191
Report Date: 06/22/2023
Date Signed: 06/22/2023 01:00:35 PM

Document Has Been Signed on 06/22/2023 01:00 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 - 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:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Nayeli Nolasco, AdministratorTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to DSP staff Rocio Tumalan. Director of Quality Assurance Claudia Lujan, Administrator Nayeli Nolasco, and Assistant Administrator Edward Ventura arrived later. There are six (6) ambulatory developmentally disabled adults ages 18-59. The facility is licensed as a level 4i specialized home vendored by Eastern Los Angeles Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility is encouraging hand washing and self symptom check of staff and visitors. Room # 2 is designated as a COVID-19 isolation room if needed. The facility has an Infection Control Plan, COVID-19 mitigation plan, and monkey pox plan.
Physical Plant/Environment Safety:
  • 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.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has two (2) fully charged fire extinguishers. Cleaning supplies and toxic substances are inaccessible to clients.

  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
See next page
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MERCEDES DIAZ HOMES INC - MAR VISTA
FACILITY NUMBER: 197803191
VISIT DATE: 06/22/2023
NARRATIVE
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Operational Requirements:
  • The Program Design is current.
  • Fire clearance has been approved for six (6) ambulatory residents.
  • Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients.
  • Current Surety bond is in place.
  • Liability insurance is in place.

Staffing:
  • A total of eleven (11) staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expires 11/23/2023.
  • Five (5) staff files were reviewed for criminal background clearance and training. Staff (S1) was not associated. Citation was issued.
  • Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.

Client Rights/Information:
  • Physician orders, and personal rights were reviewed in client files.

Client Records/Incident Reports:
  • Four (4) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, medication administration records, and P & I money.

Food Service:
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
  • Physician orders for modified diets are not in place.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
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 - MAR VISTA
FACILITY NUMBER: 197803191
VISIT DATE: 06/22/2023
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Health Related Services:
  • Clients are assisted with self administration of prescription and non-prescription medications.
  • Four (4) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental:
  • All clients have a Needs and Services Plan and COVID-19 vaccination cards on file.
  • Staff training was on file.

Disaster Preparedness, and Emergency Intervention:
  • A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.
  • An emergency drill was conducted on 6/1/2023.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.


Per California Code of Regulations, Title 22, a deficiency was cited.

Exit interview 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: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/22/2023 01:00 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/22/2023 at 12:12 PM
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: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
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: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) 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 on 5/30/2023 but has not been associated; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2023
Plan of Correction
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Corporate staff associated staff (S1) to the facility during the visit. Civil penalty was assessed. ***Cleared.
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: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
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