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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800087
Report Date: 07/22/2024
Date Signed: 07/22/2024 11:14:07 AM


Document Has Been Signed on 07/22/2024 11:14 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



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: 6DATE:
07/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:NIcole AjunwaTIME COMPLETED:
11:20 AM
NARRATIVE
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On 07/22/2024, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to commence a case management visit. LPA Brown was greeted and granted entrance by a staff. LPA Brown identified herself and discussed the purpose of the visit with Nicole Ajunwa. At the time of the visit, there were six (6) residents, and two (2) staffs present.

During today's visit, LPA Brown observed that Resident #3 (R3) has full bed rail and staff interview and records review indicated that R3's not on hospice and no exception report was submitted and approved by Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office. Deficiency will be issued.

Moreover, during the tour of the facility, LPA Brown observed Resident #2 (R2) and Resident #4 (R4), with half bed rails but staff interviews and document review indicated that there are no written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued.

An exit interview was conducted where this report (LIC809), LIC809D and Appeal Rights were discussed and provided to NIcole Ajunwa.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
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 2


Document Has Been Signed on 07/22/2024 11:14 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: MERCY HOME 3
FACILITY NUMBER: 331800087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2024
Section Cited
CCR
87608(a)(5)(B)

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87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do...(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
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Licensee stated to remove R3's full bed rail and submit proof to LPA Brown on Plan of Correction (POC) due date.
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Based on observation, interview, record review, the licensee did not comply with the section cited above by having a full bed rail for Resident #3 (R3) and R3's not on hospice and no exception was submitted and approved to CCLD which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
08/05/2024
Section Cited
CCR87608(a)(3)

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87608 Postural Supports (a) Based on the individuals preadmission appraisal....(3) A written order from a physician indicating the need for the postural support shall be maintained in the residents record. The licensing agency...
This requirement is not met as evidenced by:
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The Licensee stated to submit written order from R2 and R4 physician indicating the need for the postural support for mobility and submit proof to LPA Brown on plan of correction (POC) due date.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by having Resident #2 (R2) and Resident #4 (R4), with half bed rails with no written order from their physician indicating the need for the postural support for mobility which poses a potential health, safety and personal rights risks to resident in care.
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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) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2