<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005484
Report Date: 10/12/2022
Date Signed: 10/12/2022 03:18:42 PM

Document Has Been Signed on 10/12/2022 03:18 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
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:
10/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Mayra OrtegaTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on self-reported incident report received in the Orange County Regional Office (OCRO) on 10/10/22 regarding Resident #1 (R1). LPA met with Staff #1 (S1) Mayra Ortega. Administrator (AD) Brenda Venegas was not present during the inspection.

The incident report stated the following: On 10/05/22, R1 and R2 had an altercation where R2 hit R1 on the head with a plastic bottle, R2 called 911, police and paramedics arrived and assessed the residents, but determined no crime was committed and all residents remained at the facility. During today’s inspection, LPA conducted health and safety checks and interviewed R1, R2, and R3. LPA reviewed incident reports stating that on 09/19/22 R1 hit R3 during an altercation and on 09/30/22 R1 refused medications, became agitated, and engaged in property destruction. LPA interviewed S1 who provided the following information: R2 and R3 have been at the facility for over 2.5 years and R1 move in about 2 months ago. All residents involved in these altercations are equally responsible for instigating them, but there have been no real injuries and the residents have reconciled after the incidents resolved. During these altercations, facility staff have intervened and redirected residents. Facility staff believe that R1 is acclimating to the facility which is new to R1 and R1 is also experiencing anxiety which is the cause of R1 engaging in these altercations. R1 is scheduled to see a psychiatrist on 11/09/22 for a medication adjustment to help with the anxiety. S1 stated that the facility understands that if the altercations continue or escalate, R1 may not be compatible with R2 and R3 and there may need to be a relocation. However, S1 stated that facility staff believe this will not be necessary, that the medication change should help, and that R1 should become acclimated to the facility and that staff will continue to redirect residents as necessary.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1