198602058-11-13-2023-28-AS-JVIS-CXJVKH-20231113153023

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602058
Report Date: 11/13/2023
Date Signed: 11/13/2023 03:30:28 PM

Document Has Been Signed on 11/13/2023 03:30 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 - COGHILL		FACILITY NUMBER:	198602058
ADMINISTRATOR:	WEBB, MARSHA		FACILITY TYPE:	735
ADDRESS:	11805 COGHILL DR		TELEPHONE:	(562) 945-4576
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90601
CAPACITY: 4		CENSUS: 3	DATE:	11/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Adminsitrator Russell Johnsrud		TIME COMPLETED:	03:45 PM

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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Russell Johnsrud and the purpose of the visit was discussed. The following (12) (CARE) tool domains were utilized during the inspection:

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has an Infection Control Plan.

Operational Requirements:

A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan.
A fire clearance for four clients of which (4) may be bedridden.

Physical Plant/Environment Safety:

The facility is vendorized through Eastern Los Angeles Regional Center . The Facility is a one story residential house consists of (4) client bedrooms, Living room, kitchen, garage/laundry, sun room, activity room, and (2 1/2) bathrooms.
The physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to clients.
Fire Alarms were inspected. Fire extinguishers Observed
Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Staffing

Sufficient staff observed to meet clients needs
Facility provides care and supervision for a total of (3) Clients.

Continued on LIC 809-C

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

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 - COGHILL	FACILITY NUMBER: 198602058
	VISIT DATE: 11/13/2023

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Personnel Records-Training:

Administrator on record not updated. Current Administrators Certification is Pending Renewal from Department
Staff have criminal background clearance and training.
Six (6) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR and CPI training was observed.

Client Records-Incident Reports:

A total of three (3) client files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment / IPPs, Physician's Orders, medical consent, and medication records.
Complaint poster and Personal rights were observed posted.

Client Rights-Information

Client P&I Funds observed and safely stored
Internet source provided to clients in care

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.
An activity calendar was reviewed

Food Service:

Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies observed.
Sanitation practices and kitchen cleanliness was observed.

Incident Medical and Dental:

Three Client (3) centrally stored medications were reviewed.

Disaster Preparedness:

Emergency and Disaster Plan LIC 610D is in place.

Emergency Intervention:

There are no manual constraints in use.

Per California Code of Regulations, Title 22, NO deficiencies were cited. Visit completed using the CARE Tools Domains. Exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC809 (FAS) - (06/04)

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