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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600604
Report Date: 10/28/2024
Date Signed: 10/28/2024 04:45:04 PM

Document Has Been Signed on 10/28/2024 04:45 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/
DIRECTOR:		AKINMULERO, BOLAJI J.FACILITY TYPE:
735
ADDRESS:21362 CALORA STREETTELEPHONE:
(626) 859-4076
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 6CENSUS: 6DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Staff#1, staff-in chargeTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Staff#1 (staff in charge), who assisted with today's visit. LPA spoke with Administrator, Bolaji Akinmulero, over the phone. Today's visit was discussed. The facility is licensed to serve six (6) developmentally disabled clients, ambulatory only, ages 18-59. Annual fees are current.

Today's visit applied CARE tool, conducted physical plant, reviewed staff's files/clients' files/medication, interviewed staff/clients, and checked food supply.

The facility was a single story home, consists of four (4) bedrooms, two (2) bathrooms, kitchen with a dinning area, living room, laundry room and office in the garage. Facility maintains the required two (2) days perishable and seven (7) days non- perishable. Clients’ bedrooms were in compliance. Adequate linen and personal hygiene supply were observed. Smoke detectors and carbon monoxide detectors were operable. Hot water temperature was measured at 105.7 degree F. Medications were properly logged and current. Fire extinguisher is fully charged. The front yard is well maintained. Fire drill was conducted on 10/23/24.

Deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report was discussed with staff #1. Report was provided to staff #1, whose signature on this form confirm receipt of these documents. Appeal right was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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Document Has Been Signed on 10/28/2024 04:45 PM - It Cannot Be Edited


Created By: Bonnie Tao On 10/28/2024 at 03:59 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: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Medication cabinet was located at the corner of the living room which was not locked and accessible to clients in care.

Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Licensee agree to lock the medication cabinet and make it inaccessible to the clients in care. Licensee agreed to provide in -service training to staff to ensure the medication cabinet is locked and in compliance with the regulations. Licensee agreed to provide a statement to indicate how the facility would in compliance with section 80075(k)(1) by 10/29/24. A copy of the training log will be provided on 10/30/24.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/28/2024 04:45 PM - It Cannot Be Edited


Created By: Bonnie Tao On 10/28/2024 at 03:59 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: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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1) Client room had a broken drawer with no handles. 2) Kitchen cabinet had broken drawer with no cover/handle.
3) Front door's door trim was rotten part at the bottom.
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Licensee would have a cabinet company to repair/ re-model the kitchen to ensure all cabinets were in good repair. Licensee would repair the client's room drawer and front door's door trim. Licensee would request to extend the POC date on repair/re-model the cabinet due to cabinets/parts delivery delay. POC due by the due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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