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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602058
Report Date: 01/24/2025
Date Signed: 01/24/2025 02:34:22 PM

Document Has Been Signed on 01/24/2025 02:34 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 - COGHILLFACILITY NUMBER:
198602058
ADMINISTRATOR/
DIRECTOR:
WEBB, MARSHAFACILITY TYPE:
735
ADDRESS:11805 COGHILL DRTELEPHONE:
(562) 945-4576
CITY:WHITTIERSTATE: CAZIP CODE:
90601
CAPACITY: 4CENSUS: 3DATE:
01/24/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Administrator Mariano PrietoTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst(s) (LPA's) Jose Villalobos and Nicol Wesley conducted an unannounced case management visit regarding a client death reported on 1/16/25 to licensing. LPA's met with back up administrator Mariano Prieto.

The department received an incident report on 1/16/25 regarding the death of Client #1 (C1). It was reported that C1 passed away at PIH Whittier Hospital on 1/16/25 at 1:30am after being admitted on 1/15/25 for symptoms of being lethargic and shortness of breath. Further tests from the hospital revealed that C1 had aspiration pneumonia and a twisted intestine causing a bowel obstruction. C1 refused treatment and assistance from the hospital staff while there on 1/15/25. On 01/16/25 Hospital notes indicated C1 passed away of cardiopulmonary arrest due to small bowel obstruction.

The following documents were collected regarding C1:
  • Clients Facesheet
  • Most recent physician report
  • Most recent needs and services plan (IPP)
  • Documents of any restricted health plans
  • List of current medications
  • Hospital Notes for dates 1/15-1/16/25

On todays visit LPA's conducted a health and safety check. LPA toured the physical plant of the facility and did not observe any blocked passageways or health and safety hazards. LPA's observed the food supply to have 7 days worth of non perishables and 2 days worth of perishables available. LPA observed toxins and sharps were locked and inaccessible to clients in care.

No deficiencies are being cited at this time. Facility was advised to provide a death certificate to licensing once obtained. Exit Interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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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