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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603229
Report Date: 09/13/2022
Date Signed: 09/13/2022 10:50:16 AM

Document Has Been Signed on 09/13/2022 10:50 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. - EVELYN HOMEFACILITY NUMBER:
198603229
ADMINISTRATOR:GRISELDA ELAIRFACILITY TYPE:
735
ADDRESS:2507 EVELYN AVETELEPHONE:
(626) 872-0236
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 4CENSUS: 4DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Elvia Rojas, House ManagerTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the Infection Control domain. LPA met with the House Manager, Elvia Rojas, who assisted with the inspection. The facility is licensed to serve four (4) ambulatory adults, 18 to 59 years old. The facility has an approved mitigation plan.

LPA toured the facility with the House Manager and observed the following:

The facility has 4 bedrooms, 3 bathrooms, living room, dining room, kitchen, laundry room, and a detached garage. There is a screening station where temperature is documented for all individuals and where PPE supplies are readily available. Each client has a private room and is able to isolate in the room. The facility is able to utilize a bathroom for client to use if tested positive. The facility is well maintained with no items obstructing the passageways. LPA observed Coronavirus (COVID-19) signage throughout the facility to promote hand washing hygiene and symptom checks. The facility has at least 30 days of PPE supplies in storage. Food supplies for 2 day perishable and a week of non-perishable are also observed. Knives are locked in the kitchen cabinet and cleaning solutions/disinfectants are stored in a locked closet. The hot water temperature was measured within the required range of 105 to 120 degree Fahrenheit. Smoke and carbon monoxide combo detectors are located in each client room and throughout the house. The fire extinguishers were last inspected on 1/14/22. Medications are centrally stored and locked in the cabinet. LPA reviewed all 4 clients' medications and staff are administering them as prescribed. The facility has a Provider Information Notices (PIN) binder with the most current COVID-19 guidance from CCL. Staff are cleaning and disinfecting high touched surfaces every 4 hours and are documented.
LPA observed the facility to be following the strictest COVID-19 guidance and there are no deficiencies issued today.

An exit interview was conducted and a copy of this report was provided to Mrs. Rojas.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2022
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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