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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423609
Report Date: 07/25/2022
Date Signed: 07/25/2022 03:07:07 PM


Document Has Been Signed on 07/25/2022 03:07 PM - 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 HOMEFACILITY NUMBER:
336423609
ADMINISTRATOR:NNAMDI T. AJUNWAFACILITY TYPE:
740
ADDRESS:32350 HEARTH GLEN CTTELEPHONE:
(951) 926-0195
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:6CENSUS: 0DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mercillina AjunwaTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Jennifer Semin arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility. LPA met with Licensee/Administrator Mercillina Ajunwa. LPA advised her of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only.

LPA went over COVID-19 best practices for infection control and prevention with Ms. Ajunwa, who is successfully incorporating the facility's Mitigation Plan. There are currently no residents but hand sanitizer is available thought out the facility and the bathrooms were stocked with hand soap and paper towels. LPA observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for local fire department has been updated.

LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the central entry point for convenience. LPA observed a sufficient supply of PPE items. Gloves, face shields, gowns, surgical masks, N95 masks, disinfectant and hand sanitizer supply and is inaccessible to residents.

LPA observed a box for all PPE necessary to be dedicated for isolation room, along with trash cans to put inside and outside of an isolation room. LPA inquired as to if staff have been fit tested for N95 masks, and Ms. Ajunwa stated her, and her staff have all been fit tested and documentation is preset in staff files.

An exit interview was conducted where this report was discussed and provided to Ms. Ajunwa.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
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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