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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005484
Report Date: 10/02/2024
Date Signed: 10/02/2024 11:04:58 AM

Document Has Been Signed on 10/02/2024 11:04 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 - EMBERFACILITY NUMBER:
306005484
ADMINISTRATOR/
DIRECTOR:		VENEGAS, BRENDAFACILITY TYPE:
735
ADDRESS:651 EMBER LNTELEPHONE:
(562) 315-9824
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 4CENSUS: 4DATE:
10/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Claudia LujanTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On October 2, 2024, at 8:00am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by House Manager (HM) Elvia Rojas. HM called Director of Operations (DI) Nicole on the phone and LPA explained the purpose of the visit. Quality Assurance Director Claudia Lujan arrived around 9:30am.

The facility is licensed to operate for four (4) ambulatory clients, of which two (2) may be nonambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client bedrooms, two (2) bathrooms, living area, dining area, laundry room, kitchen, and detached 1 car garage.

LPA Kim toured inside and outside of the physical plant with HM Rojas. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Client’s rooms were inspected: Client Room 1, Client Room 2, Client Room 3, and Client Room 4. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 115.5 degrees F. A comfortable temperature of 71 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies were stored in the garage. The facility has two (2) fire extinguisher that were charged, mounted in the laundry room and in the living area, and serviced on January 25, 2024.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - EMBER
FACILITY NUMBER: 306005484
VISIT DATE: 10/02/2024
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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and clients. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (562-315-9824) remains available. First Aid kit had all the necessary elements. Emergency drills are conducted monthly and last performed on September 28, 2024.

LPA Kim conducted an audit of client files (C1-C3), staff files (S1-S3), and medication and medication administration review were all in order and complete. LPA Kim conducted one (1) staff interviews.

No Deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report was provided to Quality Assurance Director Claudia Lujan.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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