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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423609
Report Date: 02/06/2024
Date Signed: 02/06/2024 12:12:16 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
02/02/2024 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240202113050
FACILITY NAME:MERCY HOMEFACILITY NUMBER:
336423609
ADMINISTRATOR:MERCILLINA AJUNWAFACILITY TYPE:
740
ADDRESS:32350 HEARTH GLEN CTTELEPHONE:
(951) 926-0195
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:6CENSUS: 2DATE:
02/06/2024
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Mercillina Ajunwa- AdministratorTIME COMPLETED:
10:30 AM
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.
Staff do allow resident to wear their own clothes.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility to investigate and delivering findings for the above complaint allegations. LPA met with Administrator Mercillina Ajunwa and explained the reason for the visit.

During today’s visit, LPA interviewed the Administrator and one (1) additional staff.

For allegations: 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 resident’s needs, Staff scolded resident, and Staff do allow resident to wear their own clothes:

Interviews with the Administrator and an additional staff revealed that the resident involved in the complaint never lived at the facility. The resident lived at another facility that the licensee owns and operates. LPA will investigate the allegations at the correct location.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024
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 56-AS-20240202113050
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
FACILITY NUMBER: 336423609
VISIT DATE: 02/06/2024
NARRATIVE
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Based on evidence obtained during the investigation, the allegations listed above are deemed UNFOUNDED. A finding that the complaints are UNFOUNDED means that the allegations were without a reasonable basis. Therefore, the above allegations are dismissed.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Administrator Mercillina Ajunwa.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2