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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603618
Report Date: 05/30/2024
Date Signed: 05/30/2024 10:22:17 AM

Document Has Been Signed on 05/30/2024 10:22 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MERCEDES DIAZ HOMES, INC. - EL MOLINOFACILITY NUMBER:
198603618
ADMINISTRATOR/
DIRECTOR:		LUJAN-ACOSTA, CLAUDIAFACILITY TYPE:
735
ADDRESS:1200 N. EL MOLINO AVE.TELEPHONE:
(562) 945-4576
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 4CENSUS: 0DATE:
05/30/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:09 AM
MET WITH:Claudia Lujan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analysts (LPAs) Sanjay Vaid made an announced visit and met with Administrator Claudia Lujan to conduct an announced Pre-Licensing evaluation. Adult Residential Facility(ARF) to serve adults between the ages of 18 - 59. The requested capacity is for four(4) non-ambulatory clients.

Structure: Facility is a single-story home located in a residential area consisting of four(4) client bedrooms private bedrooms, two (2) bathroom, one (1) half bathroom, kitchen, dining room, living room, laundry area located in the garage area of the facility. Premises has no garage, backyard has a covered shaded area. Front yard is landscaped with grass and back yard is landscaped with cement and grass. Bedroom Clients: Each Four (4) private client bedrooms. Bedrooms are equipped with one bed, night-stand, lamp, and overhead lighting. Bathrooms: Two(2) full bathroom equipped with working toilets, wash basins, bathtub/ walk-in shower. Water temperature is within 105-120 degrees F. 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. Two (2) fully charged fire extinguishers were observed. 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. Emergency food supply was observed. Smoke Detectors: There are electrical smoke detectors located in all bedrooms, common areas, and hallways. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer are in new condition. The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked only accessible to staff.

COMP III presentation was waived, licensee has other facilities. Report was provided, and exit interview was conducted.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
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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