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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603640
Report Date: 12/03/2024
Date Signed: 12/03/2024 12:44:52 PM

Document Has Been Signed on 12/03/2024 12:44 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MERCEDES DIAZ HOMES, INC - LA CIMAFACILITY NUMBER:
198603640
ADMINISTRATOR/
DIRECTOR:
ALEGRE, CRYSTAL M.FACILITY TYPE:
735
ADDRESS:9620 LA CIMA DR.TELEPHONE:
(562) 945-4576
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 4CENSUS: 4DATE:
12/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:11 PM
MET WITH:Gabriella Ortiz - DSPTIME VISIT/
INSPECTION COMPLETED:
01:01 PM
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Licensing Program Analyst (LPA) Erik Zaragoza conducted a case management visit to follow-up on an initial case management visit that was conducted on 8/20/2024. LPA met with Gabriella Ortiz, Direct Support Staff for the facility, and explained the purpose of the visit. Evelyn Guerrero, House Manager, arrived shortly thereafter. The initial visit was conducted in response to the death of Client #1 (C1), who passed away on 8/14/2024.

During the initial visit conducted on 8/20/2024, LPA interviewed the administrator Crystal Alegre, and also obtained C1's Physician's Report, FACE Sheet, Appraisal/Needs and Services Plan, and their Medication Administration. LPA requested a copy C1's death certificate once it became available. LPA also toured the bedroom of C1 and found no concerns.

On 11/4/2024 the death certificate for C1 was provided by Crystal Alegre, which explained that the cause of death was due to Arteriosclerotic Heart Disease. The medical conditions which contributed to the immediate cause of death was a leaking heart valve. The death has been determined to not be suspicious.

At this time, no further action is required and no citations will be issued. Exit interview held and a copy of this report was provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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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