<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603638
Report Date: 12/08/2025
Date Signed: 12/08/2025 03:54:43 PM

Document Has Been Signed on 12/08/2025 03:54 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MERCEDES DIAZ HOMES, INC. - JANINE HOMEFACILITY NUMBER:
198603638
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, ALEJANDROFACILITY TYPE:
735
ADDRESS:14858 JANINE DRTELEPHONE:
(562) 945-4576
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 4CENSUS: 4DATE:
12/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Adam Elias, DSPTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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) Daniel Konishi conducted an unannounced Required 1-year visit using the full Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Adam Elias, Direct Support Staff (DSP) and LPA explained the purpose of the visit. Staff, Alan Banuelos arrived shortly after and assisted with the visit. The facility is licensed for a capacity of four (4) bedridden clients in rooms #1 to #4 and between the ages of eighteen (18) and fifty-nine (59). There are four (4) clients residing in the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility has an Infection Control Plan in place.

Physical Plant/Environment Safety: The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of four (4) bedridden clients between the ages of eighteen (18) and fifty-nine (59). It consists of four (4) client bedrooms, a kitchen, a laundry room, a dining room, and two (2) client bathrooms. LPA inspected residents’ rooms and each resident bedroom has the required furniture such as bed frames, dressers, nightstand, lamps, and chairs. Bedrooms also have sufficient closet space. Extra linens and towels are in each resident's bedroom closet. Exit doors are free of any obstruction and there are no pools or large bodies of water. The two (2) bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, non-skid mat, and bathmat. The hot water temperature readings measured 105.2 deg F in bathroom #1 and 107.6 deg F in bathroom #2 which are within the required 105-120 degrees Fahrenheit. Sharps are kept locked and inaccessible to clients.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2025
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 4
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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. - JANINE HOME
FACILITY NUMBER: 198603638
VISIT DATE: 12/08/2025
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
Physical Plant/Environment Safety [Cont.]: Toxins and Cleaning supplies are kept locked and inaccessible to clients. A shaded outdoor area for activity purposes was available for clients. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. Carbon Monoxide Detector was tested and operational. The facility has two (2) fully charged fire extinguishers that are fully charged and last inspected on 07/02/2025. Cleaning supplies and toxic substances are kept locked and inaccessible to clients.

Operational Requirements: Fire clearance was approved by LA County Fire Department for four (4) bedridden clients between the ages of 18 – 59. Valid Liability Insurance is in place. Valid Surety Bond is in place. Care and supervision to meet the clients’ needs was observed. Last Fire Drill was conducted on 12/02/2025. Last Earthquake Drill was conducted on 11/01/2025.

Staffing: A total of ten (10) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.

Personnel Records/Staff Training: Five (5) staff files were reviewed for Personnel records, Health Screening, Tuberculosis (TB) Clearance, Employee Rights, certifications, 1st Aid/CPR training, and Staff Training. Administrator certificate is valid and expires on 01/10/2027. Administrator’s file also has valid HIV and TB training.

Client Rights/Information: Client personal rights are posted. Facility has internet service accessible to all clients. Working facility phone is available and accessible to clients.

Client Records/Incident Reports: LPA reviewed four (4) client files were reviewed containing Face Sheet, Identification and Emergency Information, Admission Agreements, Physician's Report, TB clearance, Ambulatory Status, Functional Capability Assessment, Individual Program Plan, and Personal Rights. Personal and Incidental (P & I) money were reviewed.

Food Service: The kitchen was inspected and the food preparation area and storage areas were observed to be clean and sanitary. A seven (7) day supply of non-perishable food and two (2) day supply of perishable foods were observed in the kitchen. There are no clients that have a modified diet.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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. - JANINE HOME
FACILITY NUMBER: 198603638
VISIT DATE: 12/08/2025
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
Health Related Services: Clients are assisted with self-administration of prescription and non-prescription medications. Four (4) centrally stored client medication records were reviewed. Centrally stored medications are kept in a safe and locked place inaccessible to clients in care. Medications are given according to Physician directions. LPA reviewed the First Aid Kit which had all the required items.

Incidental Medical and Dental: There are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness and Emergency Intervention: The facility has an Emergency Disaster Plan in place and at least two (2) relocation sites. Last Fire Drill was conducted on 12/02/2025. Last Earthquake Drill was conducted on 11/01/2025.

Emergency Intervention: No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview was held and a copy of the report was provided to Staff, Alan Banuelos.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4