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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005484
Report Date: 11/06/2024
Date Signed: 01/17/2025 10:14:48 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2024 and conducted by Evaluator Dwayne L Mason
COMPLAINT CONTROL NUMBER: 22-AS-20240910114822

FACILITY NAME:MERCEDES DIAZ HOMES INC - EMBERFACILITY NUMBER:
306005484
ADMINISTRATOR:VENEGAS, BRENDAFACILITY TYPE:
735
ADDRESS:651 EMBER LNTELEPHONE:
(562) 315-9824
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:4CENSUS: 3DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Crystal Alegre - AdministratorTIME COMPLETED:
10:26 AM
ALLEGATION(S):
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Facility allowed access to knives
INVESTIGATION FINDINGS:
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This is an amended report.

This unannounced investigation inspection by Licensing Program Analysts (LPAs) Dwayne Mason Jr. and Samer Haddaddin is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPAs arrived at the facility and were greeted by facility staff. LPAs met with Crystal Alegra, Administrator and explained the nature of the inspection.

The department received a complaint on 9/10/2024 stating the facility allowed acces to knives. During the investigation, the Department interviewed Administrator, staff and residents in care.

(continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20240910114822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MERCEDES DIAZ HOMES INC - EMBER
FACILITY NUMBER: 306005484
VISIT DATE: 11/06/2024
NARRATIVE
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This is an amended report.

(continued from LIC9099)

On 9/16/2024 LPA Mason conducted a visit to the facility. LPA obtained electronic copies of the staff roster dated 6/6/24, resident roster dated 6/4/24, Staff schedule for the month of September 2024, Admission Agreement, Preplacement Appraisal, Dangerous Propensities document, Individual Program Plan, Functional Capabilities Assessment, Hospital visit summary and record of medical care.

LPA conducted interviews with Administrator and 2 staff (S1, S2). During 2 of these 3 interviews, facility staff stated C1 obtained a knife in the facility on 9/3/2024. On 11/6/2024, LPAs returned to the facility and conducted interviews with AD2 and one staff (S3). S3 stated C1 obtained a knife in the facility on 9/3/2024. AD2 and S3 stated a work order was made to add a component to the knife drawer lock to prevent it from being forced open. AD2 provided LPAs with a copy of the completed work order for the lock drawer. LPAs conducted interview with C1. C1 confirmed that they did obtain a knife in the facility on 9/3/2024. Of the 6 interviews conducted with AD1, AD2, C1, S1, S2 and S3, 5 out of 6 interviewed stated they were aware that C1 obtained a knife in the facility on 9/3/2024.

The preponderance of evidence standard has been met. The allegation is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240910114822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MERCEDES DIAZ HOMES INC - EMBER
FACILITY NUMBER: 306005484
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/13/2024
Section Cited
CCR
80087(g)
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(g) Disinfectants, cleaning solutions,
poisons, firearms and other items that could
pose a danger if readily available to clients
shall be stored where inaccessible to clients.
The licensee did not comply with the section
cited above due to a client being able to access a knife in the facilty's kitchen.
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Administrator stated the facility will conduct an
in-service training regarding proper storage of
sharps. Facility with send training
documentation to LPA via email by POC due
date. Facility sent completed work order to
reinforce the knife drawer lock to LPA via email.
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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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5