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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603487
Report Date: 09/08/2022
Date Signed: 09/08/2022 12:38:11 PM

Document Has Been Signed on 09/08/2022 12:38 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. - VALLEY HOMEFACILITY NUMBER:
198603487
ADMINISTRATOR:LUJAN ACOSTA, CLAUDIAFACILITY TYPE:
735
ADDRESS:1610 N. VALLEY ST.TELEPHONE:
(562) 945-4576
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 4CENSUS: 0DATE:
09/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Claudia Lujan, Administrator TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Galarza made an announced visit and met with Administrator Claudia Lujan and Executive Director of Service Development Alicia Gonzalez to conduct a pre-Licensing evaluation.

An application was submitted to Community Care Licensing Department (CCLD) for an initial application of an Adult Residential Facility Community Placement Plan (CPP) home to serve adults ages 18-59 years, level 4n The requested capacity is for two (2) non-ambulatory clients and two (2) ambulatory developmentally disabled clients. Structure: Facility is a single-story home consisting of four (4) bedrooms, two (2) full non-ambulatory bathrooms, one (1) 1/2 restroom, kitchen, dining room, living room, laundry room, and a 2-car detached garage. The front yard has a grass lawn. The backyard has shaded patio area with furniture. Bedroom Clients: All bedrooms are private. Bedrooms are equipped with one bed, night-stand, chair, lamp, and overhead lightning. Bathrooms: Have a working toilet, wash basin, and bathtub. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in bedroom closets. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. One (1) fully charged fire extinguisher is in place. Facility has a land line telephone. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Smoke Detectors: There are electrical & inter-connected smoke detectors located in all bedrooms, common areas, and hallways. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer were observed.The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked only accessible to staff.

See LIC 809C for continuation of report.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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. - VALLEY HOME
FACILITY NUMBER: 198603487
VISIT DATE: 09/08/2022
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Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C). Medication, First-Aid Kit & Book: Designated centrally stored medications are stored in the kitchen cabinets. The first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. Clients & Staff Files: Designated area for files will be in the living room. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 6/29/2022 for four (4) [2 non-ambulatory & 2 ambulatory] clients. The facility has no delayed egress. The facility is equipped with a sprinkler system. Component III: Component III was waived. Applicant is a current licensee of same category facility.

The following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA Galarza by October 6, 2022. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. The east/right side corridor exit pathway had uneven hazardous floor that was elevated posing a tripping hazard.

2. The east/right side exit pathway has two (2) crawl space access areas that need a cover.

3. The water heater needs a cabinet water heater cover.

RECOMMENDATION: The east/right side property wall does not have a privacy wall topper consistent with the rest of property. Future clients that will be served may have aggressive and property destruction behaviors that may pose neighbor safety complaint concerns.

An exit interview was conducted, and a copy of this report has been furnished to Administrator Claudia Lujan. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
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