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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004211
Report Date: 07/23/2024
Date Signed: 07/23/2024 04:34:49 PM

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
09/06/2023 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230906104946
FACILITY NAME:MERCEDES DIAZ HOMES INC - CORNISHCREST 1FACILITY NUMBER:
306004211
ADMINISTRATOR:MARIANO PRIETOFACILITY TYPE:
735
ADDRESS:13742 CORNISHCREST RDTELEPHONE:
(562) 944-2372
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY:6CENSUS: 6DATE:
07/23/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Christine AlvaradoTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff restrained resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted another visit to issue the final results of the investigation. LPA met with House manager, Christine Alvarado who assisted with the visit.

Regarding the allegation that Staff restrained resident #1. The investigation consisted of interview(s) with administrator, Staff #1 and Staff #2, and review of resident #1's file, including hospital discharge documents. Resident #1 was not interviewed due to resident #1 functioning level.

The investigation revealed that on 9/5/23 Resident #1 was transported to hospital due to pulling their foley catheter out. Administrator stated that resident #1 had a catheter in place from 8/22/23-9/7/23. Administrator and staff interviewed stated that during prior visits to the emergency room, paramedics usually place hospital mittens on resident #1, to restrain him. Administrator stated that staff "thought it was ok to put the mittens on resident #1 when he was agitated". Staff #1 and staff #2 stated that when they arrived to the facility for their shift on 9/6/23, they observed that resident #1 was in a great deal of discomfort, and had socks taped around his hands. Staff stated that they called 911 and resident was transported to the hospital.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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-20230906104946
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 - CORNISHCREST 1
FACILITY NUMBER: 306004211
VISIT DATE: 07/23/2024
NARRATIVE
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Review of resident #1 hospital discharge documents also noted the use of hand mitten restraints.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 Division 6, Chapter 1.

Exit interview conducted, and a copy of report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230906104946
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 - CORNISHCREST 1
FACILITY NUMBER: 306004211
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2024
Section Cited
CCR
80072(a)(3)
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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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Administrator will ensure that Title 22 regulations are followed as required, and residents' personal rights are not violated. Administrator will provide staff with training regarding the use of restraints, and residents' personal rights, and will send proof of training to LPA by POC due date.
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This requirement was not met as evidenced by: Based on interviews conducted, LPA learned that on 9/6/23 facility staff placed hospital socks on resident #1, and taped them to his wrists, as a restraint device. This poses a health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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
09/06/2023 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230906104946

FACILITY NAME:MERCEDES DIAZ HOMES INC - CORNISHCREST 1FACILITY NUMBER:
306004211
ADMINISTRATOR:MARIANO PRIETOFACILITY TYPE:
735
ADDRESS:13742 CORNISHCREST RDTELEPHONE:
(562) 944-2372
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY:6CENSUS: 6DATE:
07/23/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Christine AlvaradoTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff used inappropriate measures to secure resident's Foley
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted another visit to issue the final results of the investigation. LPA met with House manager, Christine Alvarado who assisted with the visit.

Regarding the allegation that: Staff used inappropriate measures to secure resident's Foley. The investigation consisted of interview(s) with administrator, Staff #1 and Staff #2, and review of resident #1's file, including hospital discharge documents. Resident #1 was not interviewed due to resident #1 functioning level.

The investigation revealed that on 9/5/23 Resident #1 was transported to hospital due to pulling their foley catheter out. Administrator stated that resident #1 had a catheter in place from 8/22/23-9/7/23. Administrator and staff interviewed stated that they did not use inappropriate measures to secure resident's foley catheter. Administrator and staff interviewed stated that the hospital staff taped the catheter to resident #1's thigh. Administrator and staff interviewed stated that Home Health was monitoring the catheter during the time period that resident #1 had a catheter in place.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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-20230906104946
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 - CORNISHCREST 1
FACILITY NUMBER: 306004211
VISIT DATE: 07/23/2024
NARRATIVE
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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 was conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5