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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005484
Report Date: 01/17/2025
Date Signed: 01/17/2025 10:12:52 AM

Document Has Been Signed on 01/17/2025 10:12 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MERCEDES DIAZ HOMES INC - EMBERFACILITY NUMBER:
306005484
ADMINISTRATOR/
DIRECTOR:		GRISELDA ELAIRFACILITY TYPE:
735
ADDRESS:651 EMBER LNTELEPHONE:
(562) 315-9824
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 4CENSUS: 4DATE:
01/17/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Elvia Rojas - SupervisorTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 1/17/2025, LPA Mason arrived at the facility to conduct a Case Management visit in order to amend a
complaint report. LPA was greeted by facility staff Elvia Rojas and explained the nature of the visit.

LPA reviewed this report and amended report with facility staff and provided copies.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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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