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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800087
Report Date: 01/05/2024
Date Signed: 01/05/2024 10:48:02 AM


Document Has Been Signed on 01/05/2024 10:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:MERCY HOME 3FACILITY NUMBER:
331800087
ADMINISTRATOR:AJUNWA, MERCILLINAFACILITY TYPE:
740
ADDRESS:36427 PISTACHIO DRIVETELEPHONE:
9515990565
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:6CENSUS: 5DATE:
01/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Margaret Muchangi- CaregiverTIME COMPLETED:
10:58 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver Margaret Muchangi and was granted entry to the facility.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents, one (1) resident may be bedridden. The current census is five (5) residents. LPA was accompanied by Caregiver to conduct a general overall inspection, which included, but was not limited to, the following:

The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility has three (3) residents (R2, R4, and R5) in care with a condition that requires auditory alarms on exterior exits. The facility does not have auditory alarms on the main entry door, the exterior sliding door leading into the backyard, and the exterior door in Resident R1’s bedroom. The facility will be issued a deficiency for not having auditory alarms on the facility exit doors. LPA measured and observed the water temperature in the bathrooms to be at 105 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident and staff files. Medications are kept inside the hallway cabinet inaccessible to residents. Non-perishable and perishable food supply is sufficient for the residents in care. Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 01/05/2024 10:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: MERCY HOME 3

FACILITY NUMBER: 331800087

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced based on interview and observation, the licensee did not comply with the section cited above evidenced by not having an auditory devices on the facility exits on the front entry door, the backdoor sliding door, and in Resident R1’s bedroom which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 01/15/2024
Plan of Correction
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The licensee has agreed to read regulation 87705 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to install auditory devices on all facility exits. POC is due by 1/15/2024.
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: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MERCY HOME 3
FACILITY NUMBER: 331800087
VISIT DATE: 01/05/2024
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LPA reviewed five (5) residents files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed two (2) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings.

Based on the observations made during today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D, and LIC811 were discussed and provided to Caregiver Margaret Muchangi, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC809 (FAS) - (06/04)
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