306004213-7-30-2026-28-AS-FFIS-DWHQME-20260731121725

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004213
Report Date: 07/30/2026
Date Signed: 07/30/2026 09:50:50 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
06/29/2026 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260629134922

FACILITY NAME:	MERCEDES DIAZ HOMES INC - CARMENITA		FACILITY NUMBER:	306004213
ADMINISTRATOR:	DOMINGUEZ, MICHELLE		FACILITY TYPE:	735
ADDRESS:	10746,10748,10750 CARMENITA RD		TELEPHONE:	(562) 944-5575
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90605
CAPACITY:	18	CENSUS: 18	DATE:	07/30/2026
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Natalie Centeno, DSP		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff allowed the client to access centrally stored medications, resulting in the client overdosing.

INVESTIGATION FINDINGS:

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***This licensing report supersedes the report dated 7/3/26 to include clarification of information regarding the client overdosing on medication. The findings remain the same, unsubstantiated.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit and met with Staff, Natalie Centeno. The purpose of this visit was explained.

The investigation consisted of the following: LPA obtained a copy of the staff roster, client roster, and reviewed medications for six (6) clients. Interviews were held with four (4) staff and five (5) clients.

Allegation - Staff allowed the client to access centrally stored medications, resulting in the client overdosing. It is alleged that the staff left the medication pill box next to the client while preparing to shower another client. Upon return, staff noticed that the client had accidentally taken the bedtime medication.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20260629134922

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERCEDES DIAZ HOMES INC - CARMENITA	FACILITY NUMBER: 306004213
	VISIT DATE: 07/30/2026

NARRATIVE

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LPA interviewed four (4) staff regarding this allegation. Staff acknowledged that the medication error occurred in house #1 (#10746) for Client #1 (C1). Staff stated that when they administer medication, they call the client one at a time. Staff stated they do not dispense medication into a pill box. Instead, staff dispense the medication into a small cup and hand it to the client to take. After the medication is completed, staff will initial the Medication Administration Record (MAR). Staff indicated that they submitted a special incident report to Licensing and Regional Center regarding this medication error. LPA reviewed the incident report provided, and the report stated that on 6/25/26, at approximately 8pm, staff accidentally administered another dose of C1’s bedtime cycle medications after it was already given. Staff immediately realized the mistake and transported C1 to the hospital for evaluation. C1 remained stable and was discharged back to the facility the next day.

LPA observed that medications are centrally stored and locked in a white cabinet in the dining area. LPA reviewed six (6) clients’ medications and did not find any discrepancies. Five (5) clients interviewed stated they receive their medication daily from staff. Based on information gathered, staff keep the medications locked at all times and do not pre-dispense medication into a pill box ahead of scheduled times. Clients do not have access to the medications for overdosing.

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.

An exit interview was conducted with Staff N. Centeno. A copy of this report, along with the appeal rights, was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC9099 (FAS) - (06/04)

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