331800087-3-4-2021-18-AS-KCLS-BYZ2TH-20210310164045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800087
Report Date: 03/04/2021
Date Signed: 03/04/2021 02:35:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/08/2020 and conducted by Evaluator Deborah Mullen

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200708165708

FACILITY NAME:	MERCY HOME 3		FACILITY NUMBER:	331800087
ADMINISTRATOR:	AJUNWA, MERCILLINA		FACILITY TYPE:	740
ADDRESS:	36427 PISTACHIO DRIVE		TELEPHONE:	(951) 599-0565
CITY:	WINCHESTER	STATE: CA	ZIP CODE:	92596
CAPACITY:	6	CENSUS: 6	DATE:	03/04/2021
		UNANNOUNCED	TIME BEGAN:	02:26 PM
MET WITH:	Mercillina Ajunwa, Licensee/Administrator		TIME COMPLETED:	02:27 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not give resident prescribed medications
Staff did not follow doctor’s orders for blood sugar checks

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Deborah Mullen contacted the Administrator Mercillina Ajunwa to deliver the findings of the above allegations. Due to COVID 19 restrictions contact was made by telephone. During the investigation LPA interviewed administrator, staff (S1), and other pertinent witnesses. Documents from resident’s (R1) file, home health records and physician were obtained and reviewed. Due to cognitive impairments R1 was not able to be interviewed.

Allegation #1 alleged resident was not given prescribed medications. The administrator and S1 stated R1 was given medications as prescribed. A copy of the Medication Administration Record (MAR), initialed by staff each time medication is administered, indicates R1 received medication as prescribed. Conflicting information received was that R1's medication bottles were empty and staff were waiting on refills.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

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 18-AS-20200708165708

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MERCY HOME 3	FACILITY NUMBER: 331800087
	VISIT DATE: 03/04/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation # 2 states staff did not follow doctor’s orders for blood sugar checks. LPA interviewed the administrator, S1, outside parties, and obtained and reviewed the Medication Administration Record (MAR). Based on the interviews and documentation, LPA was unable to corroborate the allegation that facility staff did not follow doctor's orders for blood sugar checks.

Based upon information obtained during the investigation the allegations that staff did not give resident his prescribed medications and that staff did not follow doctor’s orders for blood sugar checks are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. This report was reviewed with Ms. Ajunwa by telephone with a copy emailed for review and signature.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2