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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004660
Report Date: 11/08/2021
Date Signed: 11/08/2021 10:58:26 AM

Document Has Been Signed on 11/08/2021 10:58 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MERCEDES DIAZ HOMES INC - ACACIAFACILITY NUMBER:
306004660
ADMINISTRATOR:GRISELDA ELAIRFACILITY TYPE:
735
ADDRESS:1231 N ACACIA STTELEPHONE:
(714) 603-7850
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 5CENSUS: 2DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Erika VasquezTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Norman Woodridge conducted a Covid-19 Annual Inspection at the facility. Upon arrival, LPA met with Staff 1 (S1), Erika Vasquez, informed S1 of the purpose of the visit, and conducted a tour of the inside and outside of the facility, common areas, kitchen, bedrooms, bathrooms, and garage.

LPA discussed and observed the following:

LPA observed a 2-day supply of perishables and a 7-day supply of nonperishables. LPA observed 30-day PPE supply and hygiene products for clients. Hallways and walkways were free from obstruction and the facility placed Covid-19 related signage in the common areas of facility as well as the restrooms. LPA observed liquid hand soap and paper towels in restrooms. LPA reviewed temperature check log for clients, Covid-19 related training log for staff, staff roster, and client roster. LPA provided technical assistance on adding a one-point entry designated for screening visitors. LPA provided technical assistance on documenting temperatures for staff. LPA discussed updated Covid-19 requirements including signage, reporting requirements and mitigation planning.

No deficiencies were noted during the inspection.

An exit interview was conducted with S1 and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Norman Woodridge
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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