306004207-6-14-2022-28-AS-LMOA-CFDTBT-20220614143540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004207
Report Date: 06/14/2022
Date Signed: 06/14/2022 02:35:45 PM

Document Has Been Signed on 06/14/2022 02:35 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 - DAVENRICH		FACILITY NUMBER:	306004207
ADMINISTRATOR:	CRYSTAL ALEGRE		FACILITY TYPE:	735
ADDRESS:	11102 DAVENRICH RD		TELEPHONE:	(562) 863-1932
CITY:	SANTA FE SPRINGS	STATE: CA	ZIP CODE:	90670
CAPACITY: 5		CENSUS: 5	DATE:	06/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Nayeli Nolasco - Administrator		TIME COMPLETED:	02:50 PM

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Administrator Nayeli Nolasco and explained the reason for the visit. The facility is licensed to serve 5 ambulatory developmentally disabled adult clients. There are currently 5 ambulatory clients serviced by East Los Angeles Regional Center.

The facility is in a residential area and it is a one story family home. A tour of the single-story facility included the living room, kitchen, dining area, 5 client bedrooms, 3 bathrooms, laundry area, front yard, backyard, and detached garage.

LPA Mora conducted the tour with Nayeli Nolasco and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen and garage. Sharps were observed locked in a kitchen cabinet. Chemical and cleaning solutions are kept locked under the kitchen sink. The First Aid kit is kept above the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway cabinet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a medication cabinet located in the kitchen. Client files are kept in the medication closet. Staff files are kept at a nearby corporate office and are immediately available upon request. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed with shower mats. The water temperature was tested in all bathrooms and measured at 106.4 degrees F, which is within the required 105-120 degrees F. Two fire extinguishers were observed in the kitchen and hallway and are is fully charged. Smoke detectors combined with carbon monoxide were observed throughout the facility and in each room and were operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

(CONTINUED TO LIC 809C)

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

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 - DAVENRICH	FACILITY NUMBER: 306004207
	VISIT DATE: 06/14/2022

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LPA reviewed medication for all 5 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 5 clients and 3 staff. LPA observed administrator certificate for Nayeli Nolasco - 6054650735 with an expiration date of 12/08/2023.

Facility has 30 days supplies of Personal Protective Equipment in the garage. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

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

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

LIC809 (FAS) - (06/04)

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