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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600604
Report Date: 05/27/2025
Date Signed: 05/28/2025 02:33:49 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2025 and conducted by Evaluator Sanjay Vaid
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250522142308
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: 6DATE:
05/27/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:BLESSING UMOREN-HOUSE MANAGERTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident received unexplained bruises
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sanjay Vaid made a ten-day complaint investigation at the facility, was met by Olufunke Martins and Ionie Taibo-Direct Service Personal, House Manager Blessing Umoren was not available due to illness. LPA Vaid toured the facility with Ms. Martins and did not observe any health and safety concerns. Observed staff assisting clients ready to attend day programs.

The investigation consisted of the following: Requested, obtained and reviewed, client face sheet and identification documents, staff notes dated 5/17/25 through 05/23/25, Individual program progress reports dated 07/17/2023 and 07/17/2024, list of medications administered, SGPRC service coordinators assigned to the client.

Regarding the allegation: Resident received unexplained bruises. It is alleged that resident/client received unexplained bruises to both arms between the elbow and shoulder covering the underside areas of the clients’ arms. Five (5) out of five (5) staff interviewed have denied this allegation.
CONTINUED ON 9099C.......
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20250522142308
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MERCY RESIDENTIAL HOME
FACILITY NUMBER: 198600604
VISIT DATE: 05/27/2025
NARRATIVE
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Staff stated they are not monitoring the client on a constant 24 hours watch. Staff will observe the client during meals, outings, interactions with other clients and assist with daily living needs. Staff stated that the resident is prone to self injurious behaviors when the client does not get their own way, during this time the staff will direct and re-direct the client until compliance is established and the client has become calm. According to the client’s Individual Program Plan by the San Gabriel Pomona Regional Center dated 07/17/2023, page 7 lists the client’s self injurious behaviors. The IPP dated on 07/17/2024, page 6 explains clients reasonable progress and behaviors stating that client is non-verbal and engage in self injurious behaviors when not able to express their needs/wants, staff will redirect and try to determine the needs/wants. Client attends day program and is transported to day program company van daily. Six (6) out of six (6) clients interviewed could not corroborate this allegation. Two (2) clients are non-verbal, four (4) clients are unaware. Based upon record review and interviews conducted the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Copy of this report was given to Olufunke Martins, direct staff person.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2