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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005490
Report Date: 03/29/2022
Date Signed: 03/29/2022 10:25:22 AM

Document Has Been Signed on 03/29/2022 10:25 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MERCEDES DIAZ HOMES INC - GORDONFACILITY NUMBER:
306005490
ADMINISTRATOR:VENEGAS, BRENDAFACILITY TYPE:
735
ADDRESS:2620 GORDON AVETELEPHONE:
(562) 448-3387
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 4CENSUS: 4DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator (AD) Brenda Venegas TIME COMPLETED:
10:40 AM
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Licensing Program Analysts (LPAs ) Albert Marin and Edward Tapia made an unannounced required annual inspection in this facility. LPAs met with Administrator (AD) Brenda Venegas and stated the purpose of this visit.

The facility is a single level structure and licensed for four ambulatory of which two may be non-ambulatory. This facility offers a Level IV- N service.

About 9:05 AM, LPAs Marin and Tapia were granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPAs observed four clients in care and two staff members on the floor. LPAs toured the interior and exterior portions of the facility. There were four private client's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Hardwired smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured at 105 degrees Fahrenheit. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPAs Marin and Tapia reviewed the COVID 19 mitigation plan of the facility. LPAs discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued.

LPAs Marin and Tapia conducted an exit interview with AD Brenda Venegas ; and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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