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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603229
Report Date: 08/27/2024
Date Signed: 08/27/2024 05:11:00 PM

Document Has Been Signed on 08/27/2024 05:11 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/
DIRECTOR:		NAYELI M NOLASCOFACILITY TYPE:
735
ADDRESS:2507 EVELYN AVETELEPHONE:
(626) 872-0236
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 4CENSUS: 4DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:29 PM
MET WITH:Nayeli M Nolasco, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:19 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required - 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Nayeli Nolasco, and explained the reason for the visit. The facility is approved for serve Developmentally Disabled Adults, four (4) ambulatory clients ages 18-59.The facility is licensed as a level 1-13 home vendored by East Los Angeles Regional Center.

The following twelve (11) tool domains were observed and reviewed:

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing, still checking client temperature twice a day and staff disinfected the facility every shift. The facility has an Infection Control Plan and COVID-19 mitigation plan in place.
3. Operational Requirement: The facility is licensed for 4 ambulatory clients and currently all four (4) clients are ambulatory. The last fire/earthquake drill was conducted on 08/04/2024. Clients can attend the community events/activities if there's an opportunity and chance. The facility has a shaded area with table and chairs for client to utilize the outdoor activity area.

4.Staffing: The facility has sufficient staffing. LPA reviewed the NOC shift staff files, and they have current CPR/FIRST AID certificate. Staff need facility training on how to shut off utilities.

5. Personnel Records-Training. The facility staff files are stored at facility. All the staff are over 18 years old and older, fingerprint cleared and associated with the facility. The administrator is Nayeli Nolasco and, administrator certificate expiration date is 12/08/2025 and has her updated HIV and TB training. LPA reviewed four (4) staff files and they all have health screening TB test result.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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
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: 08/27/2024
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6. Client right-Information: Currently there's no client that required postural support. The facility has internet service and provide at least one internet access device in the facility.

7. Client Records- Incident Reports: The client files are stored in the staff office in the file cabinet. All client files have the required documents include face sheet, admission agreement, functional capability assessment, health screening and TB Test, Individual Program Plan (IPP), ambulatory status and medication list.

8. Food Service: Currently no client is on modified diet. The facility does have two days perishable and seven days non-perishable food supply. The food is stored probably. The facility refrigerator is maintained within the required temperature and is very clean.

9. Health Related Services: The medication is centrally stored and locked in the by kitchen in a cabinet. LPA inspected all four (4) clients medication, and they were all updated and accurate at the time of visit. They all have 30 days’ supply of medication.



10.Incidental Medical Services: Currently there's no client has any restricted health condition or prohibited health condition in the facility.

11. Disaster Preparedness: The facility has an emergency disaster plan and dated on 08/09/2024 and the last fire/emergency drill was conducted on 08/04/2024 and the facility has two alternative temporary shelter location. LIC 610 needs updating.

12. Emergency Intervention: The facility does not use any restraint on clients, but all staff have an updated CPI training.


No deficiencies were observed during the visit. LPA will return to complete annual inspection.
Technical Advisory provided.

Exit Interview conducted and a copy of the report was provided to Nayeli Nolasco.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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