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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603487
Report Date: 11/07/2024
Date Signed: 11/07/2024 01:44:05 PM

Document Has Been Signed on 11/07/2024 01:44 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MERCEDES DIAZ HOMES, INC. - VALLEY HOMEFACILITY NUMBER:
198603487
ADMINISTRATOR/
DIRECTOR:		LUJAN-ACOSTA, CLAUDIAFACILITY TYPE:
735
ADDRESS:1610 N. VALLEY ST.TELEPHONE:
(562) 945-4576
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 4CENSUS: 3DATE:
11/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Jesus AlaridTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the caregiver. The House Manager, Jesus Alarid arrived at 9:50 am. LPA stated the purpose of the visit was to conduct a tour of the facility, review residents' files, obtain staff work schedule, and obtain the resident roster.

LPA toured the facility at 9:50 am until 10:10 am. LPA did not observe any safety issues. LPA requested: (1) staff roster, and (2) resident roster. LPA received a copy of the staff roster and the clients' face sheets.

The Administrator Octavio Torres-Rodriguez arrived at 10:50 am and confirmed the facility is incorporated. There are no changes regarding the ownership of the facility.

Exit interview conducted and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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