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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004213
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:31:31 PM

Document Has Been Signed on 08/20/2024 02:31 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/
DIRECTOR:		DOMINGUEZ, MICHELLEFACILITY TYPE:
735
ADDRESS:10746,10748,10750 CARMENITA RDTELEPHONE:
(562) 944-5575
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 18CENSUS: 6DATE:
08/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:08 AM
MET WITH:Rosie Reynoso, administratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced Case Management- other visit in response to Eastern LA Regional Center’s report, dated 08/15/24. The facility is licensed to serve (18) developmentally disabled clients (age 18-59) and is approved for twelve (12) ambulatory and six (6) non-ambulatory. LPA explained the purpose of today's visit to Administrator Rosie Reynoso.

LPA toured the facility, interviewed Administrator and reviewed/obtained facility files. Clients were out in the day programs and staff were not in the facility while no clients presented at the facility during the day. The regional center report stated that the facility did not have sufficient staff and working hours. LPA interviewed Administrator revealed that the facility investigated this incident and found the staff’s working hours was short for about 4 hours while providing cares. LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats.

LPA obtained copies of the following documents:

· Staff roster
· Resident roster
· Week of staff working hours
· Payrolls

Deficiency was observed and citied during this visit. Refer to LIC 809D for details.

Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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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Document Has Been Signed on 08/20/2024 02:31 PM - It Cannot Be Edited


Created By: Bonnie Tao On 08/20/2024 at 09:01 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERCEDES DIAZ HOMES INC - CARMENITA
FACILITY NUMBER: 306004213

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
08/23/2024
Section Cited
CCR
80065(a)

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Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidenced by:
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Administrator agreed to provide a statement per CCR 80065 which stating how the facility would ensure the necessary services were provided to meet client's cares needs and schedule sufficient staff's working hours. by the POC due date.
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Based on observation, the number of facility did not have sufficient staff's working hours to provide the services necessary to meet clients' cares and supervision needs. This poses a potential health and safety risk to residents.
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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.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
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