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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602058
Report Date: 11/16/2021
Date Signed: 11/17/2021 08:13:51 AM

Document Has Been Signed on 11/17/2021 08:13 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 - COGHILLFACILITY NUMBER:
198602058
ADMINISTRATOR:WEBB, MARSHAFACILITY TYPE:
735
ADDRESS:11805 COGHILL DRTELEPHONE:
(562) 945-4576
CITY:WHITTIERSTATE: CAZIP CODE:
90601
CAPACITY: 4CENSUS: 4DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Octavio TorresTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with DSP II Maria Ortuno and explained the reason for the visit. Shortly after, the administrator Octavio Torres arrived and assisted with the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures and observed the food supply. Facility has submitted a mitigation plan and was approved on 4/10/21.

The facility is located at the residential neighborhood. The facility consists of living room, family room, dining area, kitchen, sun room, four residents bedrooms, two bathrooms, staff bathroom and attached garage with laundry area. All 4 resident bedrooms were toured. Each bedroom has a smoke detector, single bed, required linen and furniture, dresser, sufficient lighting and closet space. All two clients bathrooms were toured. They are clean and in good condition. The hot water tested between 113 and 116.1 degrees F which is within the Title 22 regulation. For the food supply, the refrigerator in the kitchen and garage has sufficient for two days perishable food and seven days non-perishable food. All the appliances are clean and working properly. The common areas such as living room, dining area and family room are clean and have the required furniture. The front and back yard are well maintained. The back yard has a shaded area and sitting area and the passageways and exits are free of obstruction. The carbon monoxide detectors were tested and they are inter-connected and operated well.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, social distancing and disinfecting the facility every three hours. All the bathrooms have sufficient soap, paper towels, and signs. The facility also has more than 30 days supply of PPE.

No deficiencies were found during this visit. Exit interview was conducted with administrator Octavio Torres and a copy of this report was provided.


SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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