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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004660
Report Date: 10/07/2024
Date Signed: 10/07/2024 11:07:42 AM

Document Has Been Signed on 10/07/2024 11:07 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MERCEDES DIAZ HOMES INC - ACACIAFACILITY NUMBER:
306004660
ADMINISTRATOR/
DIRECTOR:
GRISELDA ELAIRFACILITY TYPE:
735
ADDRESS:1231 N ACACIA STTELEPHONE:
(714) 603-7850
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 5CENSUS: 4DATE:
10/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Erika VasquezTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analysts (LPAs) Samer Haddadin and Claudia Gutierrez conducted an unannounced visit for the purpose of conducting an annual inspection. LPAs were greeted and granted entry. LPAs met with staff member 1 (S1) Erika Vasquez and discussed the purpose of the inspection.The facility is an Adult Residential Facility (ARF) and is licensed for 6 ambulatory clients. Currently there are four clients in care. The facility is a one-story home which houses the family room, living room, dining room, kitchen, staff office, backyard and de-attached two-car garage. The facility also has four client rooms, and two full bathrooms.Facility appears clean, safe, and sanitary. All clients’ rooms had required elements, including bed, chair, closet space, and ample lighting. Facility had extra linens and hygiene supplies for all four clients. Restrooms were stocked with soap and paper towels. Hot water measured at 109.3 degrees Fahrenheit in both bathrooms. LPAs observed the facility had a two-day supply of perishables and a seven-day supply of non-perishable food was available as required by regulations. LPAs observed hallways and walkways were free of obstruction. LPAs observed the fire extinguisher was charged based on the arrow on the extinguisher's meter pointing into the green zone. The service tag indicates the extinguisher was last serviced on October 1st, 2024. (S1) tested smoke and carbon monoxide detectors. LPAs observed the detectors to be operational.Chemicals and toxins are locked up in the hallway closet. LPAs noted the facility's knives and sharps are in the kitchen secured and locked. Medication for each client is kept locked in the staff office as well as staff and clients’ files. The backyard has one shaded seating area, and the exit gate is unlocked and unobstructed. No bodies of water observed.LPAs reviewed four clients’ files, medications, and P&I records; no discrepancies observed. LPAs reviewed two staff files. All files of staff and clients contained all required documentation. Upon review of records, the facility is up to date with required quarterly fire drill, which was last conducted in September 10, 2024. The administrator certificate expires on August 2025, 2025.Administrator Griselda Elair arrived at 10:25 a.m. No deficiencies were noted during today's inspection visit. An exit interview was conducted, and a copy of this report was provided to the facility staff.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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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