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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004207
Report Date: 08/10/2021
Date Signed: 11/15/2021 02:59:16 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2021 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210715155355
FACILITY NAME:MERCEDES DIAZ HOMES INC - DAVENRICHFACILITY NUMBER:
306004207
ADMINISTRATOR:CRYSTAL ALEGREFACILITY TYPE:
735
ADDRESS:11102 DAVENRICH RDTELEPHONE:
(562) 863-1932
CITY:SANTA FE SPRINGSSTATE: CAZIP CODE:
90670
CAPACITY:5CENSUS: 5DATE:
08/10/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:
Senior Executive Administrator Alicia Gonzalez		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident not accorded dignity in relationships with other persons.
Staff is not providing a safe environment for resident.
INVESTIGATION FINDINGS:
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This is an amended report to reflect that this is a public document. Previous LIC9099 delivered on 8/10/21 showed that it was confidential. The LIC9099 narrative and the complaint findings have not changed. On 11/15/21, LPA Glenn Trueman obtained facility representative's signature for this report.

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Caregiver Hedika Herrera. Shortly thereafter Senior Executive Administrator Alicia Gonzalez arrived and the reason for the visit was explained. The purpose of the visit is to deliver the findings from the original complaint dated 7/15/21.
In regards to the allegation Resident not accorded dignity in relationships with other persons based on interviews conducted and information gathered 3 of 4 clients interviewed stated that staff are good and they do not feel unsafe. Client 1 stated that he does have behaviors when he is mad and that staff will help talk to him and calm other clients. Said that staff will help all clients. Staff interviewed stated that this is a forensic behavior home and that there are training's for Client 1 and staff. Stated that when Client 1 has behaviors staff will redirect other clients to safety. Facility conducts resident council meetings monthly in which client's can voice any concerns. LPA observed Client 1's bedroom in the corner of the facility not close to the other client rooms. Individual Program Plan (IPP) approved on 7/14/2021 states that Regional Center will assess Client 1's
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20210715155355
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/10/2021
NARRATIVE
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placement on a quarterly basis.
Report states that Client 1 continues with psychiatric consultations and medication management's.
Client 1's behavioral Plan continues to be monitored for the following inappropriate behaviors:
banging head, property misuse and verbal aggression.
Report also states that staff at MDH Davenrich provide Client 1 with the support he needs.
Based on the information gathered and the interviews conducted: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

In regards to Staff is not providing a safe environment for resident, based on information gathered and interviews conducted LPA observed Client 1's bedroom is the corner of the facility not close to the other client rooms.
3 of 4 clients stated that the facility is safe and that staff will get involved right away to assist during any client's behavior episodes.
Staff interviewed stated that other client's will be redirected to safety when Client 1 has a behavior episode.
Staff hold resident council meetings monthly to address any concerns to ensure a safe home.
Individual Program Plan (IPP) approved on 7/14/2021 states that Regional Center will assess Client 1's placement on a quarterly basis.
Report also states that staff at MDH Davenrich provide Client 1 with the support he needs.
Client 1's behavioral Plan continues to be monitored for the following inappropriate behaviors:
banging head, property misuse and verbal aggression.

Based on the information gathered and the interviews conducted: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2