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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600604
Report Date: 11/28/2023
Date Signed: 11/28/2023 05:34:27 PM

Document Has Been Signed on 11/28/2023 05:34 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MERCY RESIDENTIAL HOMEFACILITY NUMBER:
198600604
ADMINISTRATOR:AKINMULERO, BOLAJI J.FACILITY TYPE:
735
ADDRESS:21362 CALORA STREETTELEPHONE:
(626) 859-4076
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 6CENSUS: DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Nsemeke Inyang, House ManagerTIME COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to DSP Nwakozo Okechukwu. House Manager Nsemeke Inyang arrived shortly after. There are six (6) ambulatory only level 3 developmentally disabled adults. The facility is licensed to serve residents 18-59 years old. The facility is vendored by San Gabriel/Pomona Regional Center.


Infection Control:
  • Infection control practices and Personal Protective Equipment (PPEs) were observed. An Infection Control Plan was not reviewed and staff could not find it in the premises.


Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood. It consists of 3 resident bedrooms, 1 staff room, 2 bathrooms, kitchen/dining room, living room, laundry area, outdoor patio, and an attached garage presently being used as an office

  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Electrically hard wired smoke and carbon monoxide detectors were tested and are operational. There are two (2) fire extinguishers in the kitchen.

  • Water temperature readings did not measure between the required 105 - 120 degrees Fahrenheit. Citation was issued.


****Report narrative continues next page.*****
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MERCY RESIDENTIAL HOME
FACILITY NUMBER: 198600604
VISIT DATE: 11/28/2023
NARRATIVE
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Operational Requirements:
  • Fire clearance is approved for six (6) ambulatory residents only.
  • Care and supervision to meet the clients needs was observed. Special equipment and supplies are not used by residents.
  • The facility has a Surety Bond and expires 11/12/2027.

Staffing:
  • A total of 7 staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expires 2/25/2024.
  • Four (4) staff files were reviewed. Personnel record, Criminal Record Clearance, health screening/TB clearance, training, zero-tolerance policy, and 1st Aid/CPR was on file.
  • Staff (S1) is not associated. Citation was issued.

Client Rights/Information:
  • Physician orders and personal rights were reviewed in client files.

Client Records/Incident Reports:
  • Six (6) resident files containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments and Medication Administration Records were reviewed. Personal & Incidental (P & I) monies/records were reviewed. Licensee does not keep money in the premises. House manager

Food Service:
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
  • One (1) resident has physician orders for a modified diet.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MERCY RESIDENTIAL HOME
FACILITY NUMBER: 198600604
VISIT DATE: 11/28/2023
NARRATIVE
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Health Related Services:
  • Residents are assisted with self administration of prescription and non-prescription medications.
  • Centrally stored resident medication records were reviewed. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental:
  • All residents have a Needs and Services Plan, Physician Reports, and COVID-19 vaccination cards on file.

Disaster Preparedness, and Emergency Intervention:
  • LIC 610D Emergency Disaster Plan that contains emergency evacuation information has been developed. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility.
  • First Aid Kit and Manual were observed.
  • The last emergency drill was conducted on 9/25/2023.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.

Per Title 22, California Code of Regulations, deficiencies were cited.


Exit interview conducted with House Manager Nsemeke Inyang. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
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Document Has Been Signed on 11/28/2023 05:34 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/28/2023 at 04:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERCY RESIDENTIAL HOME
FACILITY NUMBER: 198600604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)(1)(A-F)
INFECTION CONTROL REQUIREMENTS. An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. The Infection Control Plan shall include all of the following: Identification of a staff position to perform the duties of an Infection Preventionist for the facility. (B) A description of how the licensee shall meet the specific infection control practice requirements of subsections (a), (b) and (d). An Infection Control Training Plan. The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. The licensee shall ensure that staff encourage clients to follow infection control practices as necessary. Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff were not able to find an infection control plan; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2023
Plan of Correction
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Administrator shall develop and submit a copy of the Infection Control Plan.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


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Document Has Been Signed on 11/28/2023 05:34 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/28/2023 at 04:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERCY RESIDENTIAL HOME
FACILITY NUMBER: 198600604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA observed disinfectant/cleaning products, knife, and lighters were observed unlocked in storage cabinets; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2023
Plan of Correction
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Administrator shall conduct staff training and submit proof of training/staff signatures by tomorrow.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the bathroom hot water measured 122.9 DF; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2023
Plan of Correction
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Administrator shall submit a hot water temperature log indicating the water was tested 3 times a day. Submit pictures of the hot water temperature readings. POC is due tomorrow.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


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Document Has Been Signed on 11/28/2023 05:34 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/28/2023 at 04:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERCY RESIDENTIAL HOME
FACILITY NUMBER: 198600604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff (S1) began working at the facility on 6/7/2023 but has not been associated; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2023
Plan of Correction
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Staff (S1) shall be associated to the facility by tommorow via Guardian or staff can drop off transfer request at CCL office. Civil penalty was assessed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


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