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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603639
Report Date: 12/05/2024
Date Signed: 12/05/2024 12:46:38 PM

Document Has Been Signed on 12/05/2024 12:46 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 - VALEFACILITY NUMBER:
198603639
ADMINISTRATOR/
DIRECTOR:		COLLAR, NICOLEFACILITY TYPE:
735
ADDRESS:7751 VALE DR.TELEPHONE:
(562) 945-4576
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY: 4CENSUS: 4DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Steven Rodriguez, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to staff Beatriz Krenz. Assistant Administrator Steven Rodriguez arrived shortly after. The facility is licensed as a level 4 N Adult Residential Facility for four (4) residents [three (3) bedridden and (one) non-ambulatory] developmentally disabled adults ages 59 and under vendored by Eastern Los Angeles Regional Center. The following 12 Care Compliance and Regulatory Enforcement (CARE) tool domains were utilized during the inspection.

The following were observed/inspected:



Infection Control: The Infection Control Plan was reviewed. The facility has sufficient supply of Personal Protective Equipment (PPEs).

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that is licensed for three (3) bedridden clients, and one (1) non-ambulatory client. It consists of 4 client bedrooms, 2 living rooms, dining area, kitchen, 3 bathrooms, laundry room, backyard patio area, and a detached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility has three (3) fully charged fire extinguishers and fire sprinklers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has a 1st Aid Kit and Manual.

Operational Requirements: Fire clearance was approved on 1/17/2023 for one (1) non-ambulatory and three (3) bedridden residents. Care and supervision to meet the clients needs was observed. Special equipment and supplies are used by non-ambulatory residents. The Surety Bond is current with expiration date of 10/1/2025.



Staffing: A total of 10 staff members provide care and supervision to the clients.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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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 - VALE
FACILITY NUMBER: 198603639
VISIT DATE: 12/05/2024
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Personnel Records/Staff Training: Administrator certificate expires 6/17/2026. Staff have criminal background clearance and training. Four (4) staff files were reviewed. Proof of staff training, health and TB clearance, and 1st Aid/CPR training are on file. Proof of in-service training that includes HCBS Final rule was observed in staff files.

Client Rights/Information: Physician orders and personal rights were reviewed in client files.

Client Records/Incident Reports: Four (4) resident files were reviewed. Admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, Personal & Incidental (P & I) monies/records, Medication Administration Records, and HCBS Tenant/Landlord Agreements were reviewed.

Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Three (3) residents have modified diets.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Centrally stored resident medication records were reviewed and are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental: All residents have a Needs and Services Plan, Physician Reports, and COVID-19 vaccination cards on file.

Disaster Preparedness, and Emergency Intervention: A posted LIC 610D Emergency Disaster Plan was observed. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. First Aid Kit and Manual were observed. The last emergency drill was conducted on 11/1/2024.

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

No deficiencies were observed.



Exit interview was conducted with Assistant Administrator Steven Rodriguez. A copy of the report was issued electronically due to printing issues.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
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