306004207-4-9-2026-28-AS-LHIS-DSZTH4-20260410144407

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004207
Report Date: 04/09/2026
Date Signed: 04/09/2026 09:42:47 AM

Substantiated

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
11/04/2025 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20251104100804

FACILITY NAME:	MERCEDES DIAZ HOMES INC - DAVENRICH		FACILITY NUMBER:	306004207
ADMINISTRATOR:	NAYELI NOLASCO		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:	04/09/2026
		UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Hedika Herrera, House Manager		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Staff did not seek timely medical attention for a client.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings. The purpose of the visit was explained to House Manager Hedika Herrera. Administrator Nayeli Nolaso was explained the purpose of the visit telephonically.

The investigation consisted of: On 11/6/2025, a physical plant tour of the facility was conducted. Residents (R1-R4), staff (S1- S5), and pharmacist were interviewed. Resident (R5) declined to be interviewed. Record review was completed. Copies of R1's Profile, Individual Program Plan (IPP), Physician's Report, Medication Administration Record (MAR- November 2025), Daily ID Notes [10/28/25- 11/5/25], Record of Medical Care Notes [12/19/24- 10/28/25], Quarterly Progress Report , Incident Report [11/2/2025], LIC 500 Personnel Report and Register of Facility Residents were obtained. CT Scan results and hospitalization record/treatment summary was submitted at a later date.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

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 5

Control Number 28-AS-20251104100804

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: 04/09/2026

NARRATIVE

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Allegation: Staff did not seek timely medical attention for a client. It is alleged that resident (R1) was constipated for at least two weeks prior to November 1, 2025 with visible stomach distention despite using laxatives. It was reported that staff did not take the resident to see a doctor until their prescheduled follow-up CT scan results doctor's visit on October 28, 2025. Resident interviews revealed that R1 complained about stomach pain 5-6 days prior to emergency incident. Staff stated that R1 has history of somatic complaints and that the resident likes medical attention. Staff stated that R1 had a CT scan of abdomen/pelvis on September 22, 2025. The resident saw a physician assistant on October 28, 2025 who prescribed Bisacodyl EC 5 MG Morning and afternoon, and Constulose 10 mg morning and bedtime. The facility received the bubble pack medications on October 29, 2025, but did not administer the medications until November 1, 2025. Based on interviews and record review, the findings indicate staff were aware R1 had stomach pain/discomfort days prior and noticed loss of appetite, but delayed medical attention addressing R1's bowel/stomach issues until the pre-scheduled visit on October 28, 2025 to obtain CT scan results. Staff had knowledge that the resident was constipated and did not have any constipation medications. Despite observing R1 unwell on October 31, 2025 staff did not transport the resident to urgent and/or emergency care. Therefore, there is sufficient information to support the allegation.

Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, a deficiency was cited.

An exit interview conducted, copy of the report and appeal rights was provided to House Manager Hedika Herrera.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20251104100804

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/23/2026 Section Cited CCR 80065(f)(5)	1 2 3 4 5 6 7	Personnel Requirements. All personnel shall be given on-the-job training ..... Recognition of early signs of illness and the need for professional assistance. This requirement was not met evidenced by:	1 2 3 4 5 6 7	Administrator shall submit: 1. A plan addressing prompt medical care when necessary. 2. Staff In-service training
	8 9 10 11 12 13 14	Based on record review and interviews conducted, R1 complained of stomach pain/discomfort & constipation for approximately 1 week prior to their CT scan results appointment (10/28/25), at which MD prescribed constipation medications that were received on 10/29/25, but administered until 11/1/25. This posed a potential health risk.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
11/04/2025 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20251104100804

FACILITY NAME:	MERCEDES DIAZ HOMES INC - DAVENRICH		FACILITY NUMBER:	306004207
ADMINISTRATOR:	NAYELI NOLASCO		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:	04/09/2026
		UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Hedika Herrera, House Manager		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Staff did not timely address a client's change in medical condition.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20251104100804

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: 04/09/2026

NARRATIVE

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Allegation: Staff did not timely address a client's change in medical condition. The complaint alleges resident (R1) did not have a bowel movement in weeks, was in extreme pain, and upon visual observation the resident's abdomen was distended. It was reported that staff did not know R1's medical history. Four (4) residents were interviewed. All residents stated they are regularly taken to doctor appointments. Resident (R1) stated they have history of constipation and did not have major stomach pain or vomiting until 11/1/2025, but had been experiencing stomach pain for at least 1 week. Staff interviews revealed that R1 has had multiple visits with Gastroentorologist and primary care physician to address constipation. On July 14, 2025, R1 had an initial appointment with the GI specialist that determined the resident needed a CT scan. This was the initial visit from the referral. It was determined that the resident needed to get an authorization for a CT scan . The CT scan was performed on September 22, 2025. CT scan results were provided until October 28, 2025, which determined that R1 had severe bowel retention and a colonoscopy was needed within 2-3 weeks.

The emergency hospital visit on November 1, 2025 resulted in an emergency bowel resection surgery to remove bowel obstruction. LPA reviewed facility documents: hospital discharge orders, Quarterly Progress Report states R1 has history of somatic complaints i.e., abdominal pain and records of Medical Care dates 12/19/2024. 4/22/25, 6/3/2025, 6/12/25, 7/14/25, 9/23/25, and 10/28/2025. Subsequent visits [6/12/25, and 7/14/25, 9/22/25] addressed gastrointestinal bloating, distention, and CT scan exams. On July 14, 2025, a GI exam was completed due to enlarged abdomen. On October 28, 2025, R1 had a follow-up medical visit to obtain CT scan results. The findings indicate the resident's abdominal pain and constipation were addressed prior to the emergency medical incident. There is not sufficient evidence to support the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted with House Manager Edika Herrera. A copy of the report was issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC9099 (FAS) - (06/04)

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