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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003911
Report Date: 05/12/2023
Date Signed: 05/16/2023 09:13:05 AM

Document Has Been Signed on 05/16/2023 09:13 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MERCEDES DIAZ HOMES INC - CORNISHCREST 2FACILITY NUMBER:
306003911
ADMINISTRATOR:RINCON, EVERFACILITY TYPE:
735
ADDRESS:13617 CORNISHCREST RDTELEPHONE:
(562) 946-3614
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 5CENSUS: 5DATE:
05/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Russell JohnsrudTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Angelica Rea made an unannounced visit to Mercedes Diaz Homes Inc - Cornishcrest 2. The purpose of today’s visit was to conduct the required Inspection. On today’s visit LPA met with Administrator, Russell Johnsrud. The home has 5 residents, 2 non-ambulatory, and 3 ambulatory. The facility conducted a fire drill on 4/19/23.

As a part of the inspection, LPA reviewed (5) client records, (4) staff files, and (3) client medications. Facility is a one story family home with five (5) bedrooms. Each bedroom is for one (1) client. There are (2) bathroom(s) for client use. There is also a living room, a kitchen, central air and heating, a dining area, a shaded area located in the backyard. A detached car garage inaccessible to clients. Front and back yard is in good condition at time of visit. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to clients. Bedrooms #1-#5 are equipped with a (1) beds each, a dresser, lamp, chair, overhead lightning for each client. The facility has 2 bathrooms which have a working toilet, wash basin, and shower. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies were observed. Fire alarms/ Carbon Monoxide detectors are interconnected and operational. Required postings observed. Water temperature within required tittle 22 regulations.

No deficiencies cited. An exit interview was conducted and a copy of this report was provided to Administrator, Russell Johnsrud.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023
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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