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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603229
Report Date: 09/23/2023
Date Signed: 09/23/2023 03:19:26 PM

Document Has Been Signed on 09/23/2023 03:19 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
GREATER LA AC/SC, 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:
09/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Nayeli NolascoTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 09/23/2023. LPA Ramirez was met by staff #1 (S1) explained the purpose of the visit. The facility is licensed serve four (4) developmentally disabled clients 18-59 years old. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 11:15 am and was led by S1. The facility is a single-story building located in a residential area with four (4) client bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached garage, front yard, backyard.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to four (4) out of four (4) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to four (4) out of four (4) clients in care. LPA Ramirez observed a fully charger fire extinguisher nearby.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed with plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed signage promoting cough and hand washing etiquette in this area. LPA Ramirez observed nearby thermostat to read 70 degree F.

Linen Closet/Supply Closet: Contained plenty linens, towels, and hygiene products. LPA Ramirez observed extra cleaning supplies and disinfectants in this area.

Client Rooms 1 - 4: LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez observed all rooms to be clean.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2023
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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Document Has Been Signed on 09/23/2023 03:19 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/23/2023 at 02:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERCEDES DIAZ HOMES, INC. - EVELYN HOME
FACILITY NUMBER: 198603229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, personnel records were not maintained at the facility site, the licensee did not comply with the section cited above in 4 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2023
Plan of Correction
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Licensee will develop a plan to address how the facility will maintain personnel records at the facility site and maintain personnel records at the facility site moving forward. Correction must be submitted via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2023


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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MERCEDES DIAZ HOMES, INC. - EVELYN HOME
FACILITY NUMBER: 198603229
VISIT DATE: 09/23/2023
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Bathroom 1-3: Water temperature in client bathroom#1 was measured at 108.7 degrees F which is in the required 105 – 120 degrees F. LPA Ramirez observed signage promoting proper handwashing etiquette near sink. LPA Ramirez observed locked cabinet in this bathroom that contained extra hygiene supplies and toiletry items. Client bathroom #3 water temperature was measured at 116.7 degrees F. LPA Ramirez observed grab bars in all showers and non slip mats in all bathroom showers. Water temperature in private client bathroom#2 was measured at 114.8 degrees F which is in the required 105 – 120 degrees F. LPA Ramirez observed signage promoting proper handwashing etiquette near sink.

Centrally Stored Medications: LPA Ramirez observed medications to be locked in file cabinet located in kitchen area.

Backyard: No large bodies of water were observed.

Garage: LPA Ramirez observed emergency water supply, emergency food supplies and PPE in this area. Facility staff keep extra toiletry supplies in this area. All supplies were kept in locked cabinets. LPA Ramirez observed C1 visiting with loved ones in this area.

Emergency Drills (Conducted every 6 months): Proof of last documented fire drill was conducted on 9/18/23 at 6:30 pm.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Personnel files were not maintained at the facility site. Administrator Nayeli M Nolasco asked another staff member to bring personnel files. Staff files arrived within one (1) hour. LPA Ramirez issued type B deficiency for failure to personnel records at the facility site. LPA Ramirez reviewed three (3) personnel records. LPA Ramirez reviewed facility van insurance and current registration. LPA Ramirez observed a current Administrator’s certificate for Nayeli M Nolasco with an expiration date of 12/8/23.

Client Files: Four (4) client files were reviewed.

Infection Control Plan: LPA Ramirez reviewed current approve Infection Control Plan.

One (1) deficiency is being cited. Exit interview was conducted with Administrator Nolasco and a copy of this report, 809-D, and appeals rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023
LIC809 (FAS) - (06/04)
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