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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602058
Report Date: 01/26/2023
Date Signed: 01/26/2023 10:16:22 AM

Document Has Been Signed on 01/26/2023 10:16 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: 3DATE:
01/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Octavio Torres (Administrator)TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced Case Management visit to follow up on the death of Client #1. LPA met with Octavio Torres (Administrator) and explained the purpose of the visit.

Per information provided by the facility, Client #1 was admitted to Beverly Hospital ICU on 01/19/23 due to trouble breathing and lip turning blue. Family was notify and visited Client #1 in the hospital on 01/20/23. The co-conservator then took the decision to request the attending Physician to place Client #1 on DNR and take comfort measures. Client #1 passed away on 01/22/23.

LPA requested a copy Client #1's:

1) Physician Report
2) Needs and Services Plan
3) Appraisal
4) MAR
5) Hospital Records
6) Facesheet
7) Death Certificate

Facility was unable to provided death certificate. Administrator was informed to provide the death certificate once available. Until cause of death is confirmed, investigation will continue.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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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