198603229-9-9-2025-28-AS-ALOZ-DLD2JZ-20250909172710

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603229
Report Date: 09/09/2025
Date Signed: 09/09/2025 05:27:21 PM

Document Has Been Signed on 09/09/2025 05:27 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 HOME		FACILITY NUMBER:	198603229
ADMINISTRATOR/ DIRECTOR:	NAYELI M NOLASCO		FACILITY TYPE:	735
ADDRESS:	2507 EVELYN AVE		TELEPHONE:	(626) 872-0236
CITY:	ROSEMEAD	STATE: CA	ZIP CODE:	91770
CAPACITY: 4		CENSUS: 4	DATE:	09/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:37 AM
MET WITH:	Dania De la Riva, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:29 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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 Dania De La Riva 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 4N home vendored by East Los Angeles Regional Center. The following twelve (12) 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. 2. Physical Plant The facility has 4 bedrooms, 3 bathrooms, living room, dining room, kitchen, laundry room, and a detached garage. PPE supplies are readily available. The facility is well maintained with no items obstructing the passageways. 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 between 121.8 – 125.4 which is not within departmental regulations of 105.0 – 120.0 degrees Fahrenheit. Smoke and carbon monoxide combo detectors are in each client room and throughout the house. The fire extinguishers were last inspected on 09/03/2025. 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 08/04/2025. Clients can attend community events/activities if there's an opportunity and chance. The facility has a shaded area with table and chairs for clients to utilize the outdoor activity area. (Continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 5

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: 09/09/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(continued form 809)
4) Staffing: The facility has sufficient staffing. LPA reviewed the NOC shift staff files, and they have the current CPR/FIRST AID certificate.

5. Personnel Records-Training. The facility staff files are stored at the facility. All the staff are over 18 years old and older, fingerprint cleared and associated with the facility. The administrator is Dania De La Riva and, Administrator certificate expiration date is 05/10/2026 and has her updated HIV and TB training. LPA reviewed four (4) staff files, and they all have health screening and TB test result.

6. Client right-Information: Currently there's no client that requires postural support. The facility has internet service and provides 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 including 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 a modified diet. The facility does have two (2) days perishable and seven (7) 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 by kitchen in a cabinet. LPA inspected all four (4) clients medication files, 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 who has any restricted health condition or prohibited health condition in the facility.

11. Disaster Preparedness: The facility has an emergency disaster plan and conducted disaster drill on 6/08/2025 and the last fire/emergency drill was conducted on 05/13/2025 and the facility has two alternate temporary shelter locations.

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

Deficiencies was observed during the visit. Technical Advisory Provided.

Exit Interview conducted and a copy of the report was provided to Dania De La Riva

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 09/09/2025 05:27 PM - It Cannot Be Edited

Created By: Alberto Lopez On 09/09/2025 at 05:14 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: 09/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Hot water temperature measured 121.8 - 125.4 which is out of range of 105.0 - 120.0 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2025
	Plan of Correction
1 2 3 4	Administrator will adjust water keep water log for 3 days and send to LPA as proof of correction by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:

	Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5