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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004213
Report Date: 07/20/2022
Date Signed: 07/26/2022 03:30:51 PM

Document Has Been Signed on 07/26/2022 03:30 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 - CARMENITAFACILITY NUMBER:
306004213
ADMINISTRATOR:DOMINGUEZ, MICHELLEFACILITY TYPE:
735
ADDRESS:10746,10748,10750 CARMENITA RDTELEPHONE:
(562) 944-5575
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 18CENSUS: 17DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Blanca Ramirez & Edward VenturaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced Annual Required visit. LPA Rea met with Home supervisor Blanca Ramirez at the facility. Please note this facility has three (3) separate homes with 3 different addresses:10746, 10748 and 10750 on one lot under the same facility number. LPA Rea informed Ms. Ramirez that the purpose of today's visit was to conduct the facility annual inspection, review the facility infection control practices, physical plant, medications, food service, and staff records at each facility. Facility administrator Edward Ventura arrived at the facility a short time later and assisted with today's visit.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathroom(s) are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. The hot water temperature measured between 105* F - 120* F at all 3 homes. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors/carbon monoxide detectors located throughout the facilities, tested and operating. LPA observed infection control signs posted and sufficient PPE supplies. LPA observed a sufficient supply of food at all 3 home(s).

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies cited. Exit interview held and a copy of the report provided to Mr. Ventura.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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