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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423609
Report Date: 03/24/2023
Date Signed: 03/24/2023 10:02:49 AM


Document Has Been Signed on 03/24/2023 10:02 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 HOMEFACILITY NUMBER:
336423609
ADMINISTRATOR:NNAMDI T. AJUNWAFACILITY TYPE:
740
ADDRESS:32350 HEARTH GLEN CTTELEPHONE:
(951) 926-0195
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:6CENSUS: 2DATE:
03/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Mercillina "Mercy" Ajunwa-AdmTIME COMPLETED:
10:12 AM
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility to follow up on a confirmation of removal. LPA met with Administrator Mercillina "Mercy" Ajunwa.

The individual named in notice of exclusion letter dated 2/15/2023 is Kaprese Johnson.

LPA reviewed the staff schedule and verified that Kaprese is not working at the facility. Based on evidence obtained during today's visit, LPA verified that the individual is not present, employed, or residing at the facility.

LPA was informed by Administrator that Kaprese does not currently work at the facility. Kaprese has not worked at the facility since 2018. It is possible that Kaprese may appeal the exclusion. Mercillina "Mercy" Ajunwa understood that during this process Kaprese cannot work, reside, or be present at a licensed facility.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to Mercillina "Mercy" Ajunwa. Verification of removal is complete.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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