331800087-12-17-2024-56-AS-EMAN-DC8N5M-20241223090945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800087
Report Date: 12/17/2024
Date Signed: 12/17/2024 02:21:30 PM

Unsubstantiated

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2024 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20240715160448

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: 5	DATE:	12/17/2024
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Licensee/Administrator Mercelina Ajunwa		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not seek timely medical attention for a resident.
Staff did not properly report an incident involving a resident.

INVESTIGATION FINDINGS:

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On 12/17/2024 at 01:40 PM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to deliver the findings of the above allegations. LPA Brown was greeted and granted entrance to the facility by a staff. Licensee/Administrator Mercelina Ajunwa was contacted and arrived during the visit and met with LPA Brown. LPA Brown explained the purpose of today's visit to Licensee/Administrator Ajunwa.

The investigation was conducted by LPA Brown. The investigation consisted of file review and interviews with relevant parties. The first allegation indicates staff did not seek timely medical attention for a resident. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interview with three (3) of three (3) staff indicated that they all seek timely medical attention for their residents if needed. Three (3) of three (3) staff indicated that on 07/13/2024, no incident happened to Resident #1 (R1) that R1 needs timely medical attention. Staff #1 (S1) informed LPA Brown that S1's Licensed ***Continuation in LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20240715160448

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
, CA 92507

FACILITY NAME: MERCY HOME 3	FACILITY NUMBER: 331800087
	VISIT DATE: 12/17/2024

NARRATIVE

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Professional and S1 reported to LPA Brown that S1 assessed R1 on 07/13/2024 after S1 observed R1's blinking R1's eyes for two (2) or three (3) seconds but it did not continue. S1 indicated that S1 did not observed any changes on R1 that will require immediate medical attention. Interviews with two (2) of two (2) residents indicated that staffs at the facility are seeking timely medication for them. LPA Brown unable to interview three (3) residents at the facility as one (1) resident is not oriented, one (1) resident with family, and one (1) resident was sleeping.

The second allegation indicates staff did not properly report an incident involving a resident. Interview with three (3) of three (3) staff indicated that they are properly reporting all incidents involving a resident at the facility to their family, physician and Community Care Licensing Division (CCLD). S1 reported to LPA Brown that there's no incident that happened to R1 on 07/13/2024 that needs to be reported as no changes was observed to R1. S1 added that after R1's family visit on 07/13/2024, that same day, as a courtesy, S1 called R1's family/Power of Attorney(POA) and Fiduciary and S1 provided updates on R1's family visit to R1. R1 Family member/POA reported to LPA Brown that they are in close contact with S1 and all issues involving R1 were properly reported to them. Interviews with two (2) of two (2) residents indicated that staffs at the facility are reporting all incidents that are happening at the facility to their family. LPA Brown unable to interview three (3) residents at the facility as one (1) resident is not oriented, one (1) resident with family, and one (1) resident was sleeping.

Based on interviews and records review, the allegations staff did not seek timely medical attention for a resident (Allegation #1) and staff did not properly report an incident involving a resident (Allegation #2) are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, where this report (LIC9099) was discussed and provided to Licensee/Administrator Mercelina Ajunwa.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

LIC9099 (FAS) - (06/04)

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