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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800087
Report Date: 02/13/2025
Date Signed: 02/13/2025 04:58:14 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
02/06/2024 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240206100424
FACILITY NAME:MERCY HOME 3FACILITY NUMBER:
331800087
ADMINISTRATOR:AJUNWA, MERCILLINAFACILITY TYPE:
740
ADDRESS:36427 PISTACHIO DRIVETELEPHONE:
(951) 599-0565
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:6CENSUS: 4DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Licensee/Administrator Mercelina AjunwaTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff do not assist resident out of bed.
Staff do not administer resident's medication as prescribed.
The facility does not provide adequate meals to meet residents needs.
Staff scolded resident.
Staffs do not allow resident to wear their own clothes.
INVESTIGATION FINDINGS:
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On 02/13/2025 at 04:30 PM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to deliver findings on a complaint investigation. LPA Brown was greeted and granted entrance to the facility by Licensee/Administrator Mercilina Ajunwa. 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, observations and interviews with relevant parties. The first allegation indicates staff do not assist resident out of bed. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interview with two (2) of two (2) residents indicated that staffs at the facility are assisting them out of bed. Two (2) of two (2) staffs interviewed reported that they are assisting their residents out of their bed. Interviews with two (2) of two (2) staffs revealed that Resident #1 (R1)'s two (2) persons assist and they are always assisting R1 out of bed.
***Continuation in LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
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 3
Control Number 56-AS-20240206100424
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: 02/13/2025
NARRATIVE
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R1 Hospice Care Nurse Director shared that the hospice care team did not report any incident that the staffs at the facility are not assisting R1 out of bed. In addition, R1 Hospice Care Nurse Director reported that the hospice care team did not report any neglect by a staff at the facility to R1 or other residents. Also, R1 Hospice Care Nurse Director indicated that R1 skin's dry, fragile, and R1 does not have enough nutrition which makes R1 high risk and prone for skin breakdown at any time and not from poor care of the staffs at the facility. During the facility visit on 07/22/2024, 12/03/2024 and 12/17/2024, LPA Brown observed staff assisting their residents out of bed.

The second allegation indicates that staffs do not administer medications as prescribed. Interview with two (2) of two (2) residents indicated that staffs are giving their medications daily and administering their medications as prescribed by their physician. Two (2) of two (2) staffs interviewed reported that they are giving their residents medications per their doctor's order. Staff #1 (S1) reported to LPA Brown that there's no incident that happened at the facility that they placed two (2) medication patches on R1 and R1's family member cancelled the prescription. Interview with Hospice Care Nurse Director indicated that the hospice care team did not report staffs at the facility are not administering R1's medication as prescribed. During the facility visit on 07/22/2024, 12/03/2024 and 12/17/2024, LPA Brown noted that staffs at the facility are utilizing Medication Administration Record (MAR) to ensure that they are administering their residents medications as prescribed by their doctor. Moreover, LPA Brown audited two (2) residents medications on 12/03/2024 and observed that staffs at the facility are administering their residents medications as prescribed by their doctors.

The third allegation indicates that the facility does not provide adequate meals to meet residents needs. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interview with two (2) of two (2) residents indicated that the facility's providing them adequate meals to meet their needs and they can get second serving of food if they prefer. Two (2) of two (2) staffs interviewed reported that they are serving their residents adequate meals everyday and there's no incident that they did not provide adequate meals to their residents and they did not meet their needs. Two (2) staffs interviewed shared that they are providing adequate meals for R1. Hospice Care Nurse Director informed LPA Brown that the hospice care team did not report an incident that the facility's not providing adequate meals to R1 and not meeting R1's needs. During the facility visit on 07/22/2024, 12/03/2024 and 12/17/2024, LPA Brown observed that the facility's serving adequate and nutritious meals to their residents to meet their needs.

The fourth allegation indicates that staff scolded resident. Interview with two (2) of two (2) residents indicated ***Continuation in LIC9099C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20240206100424
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: 02/13/2025
NARRATIVE
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that there's no incident at the facility that a staff scolded and yelled at them. Two (2) of two (2) staffs interview reported that they never scolded R1 or their residents and they did not yell at R1 or their residents. Hospice Care Nurse Director stated that the hospice care team did not report an incident at the facility that a staff scolded or yelled at R1 or their other residents. During the facility visit on 07/22/2024, 12/03/2024 and 12/17/2024, LPA Brown observed that staffs at the facility are providing care and supervision to their residents and they are not scolding or yelling at their residents.

The fifth allegation indicates staff do not allow resident to wear their own clothes. Interview with two (2) of two (2) residents indicated that they are wearing their own clothing that they prefer to wear and there's no incident at the facility that a staff did not allow them to wear their own clothes. Two (2) of two staff interviewed reported that their residents are wearing their own clothing. Interviews with two (2) of two (2) staffs revealed that they never restricted R1 or their residents to wear their own clothing. Hospice Care Director reported that the hospice care team did not report any incident that staffs at the facility are not allowing R1 or their residents to wear their own clothing. During the facility visit on 07/22/2024, 12/03/2024 and 12/17/2024, LPA Brown observed that residents at the facility are wearing their own clothes and staffs at the facility did not prohibit them from wearing their own clothes.

Based on interviews and records review, the allegation that Staff do not assist resident out of bed (Allegation #1), Staff do not administer resident's medication as prescribed (Allegation #2), The facility does not provide adequate meals to meet residents needs (Allegation #3), Staff scolded resident (Allegation #4), Staffs do allow resident to wear their own clothes (Allegation #5) 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 Mercilina Ajunwa.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3