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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423609
Report Date: 10/25/2023
Date Signed: 10/25/2023 11:33:22 AM

Substantiated


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
04/30/2021 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210430143456
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: 3DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mercillina Ajunwa- AdministratorTIME COMPLETED:
11:42 AM
ALLEGATION(S):
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Licensee did not provide a 60 day written notice of rate increase to a resident's representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to investigate and deliver findings for the allegation listed above. LPA stated the purpose of the visit and was granted entry and met with Administrator Mercillina Ajunwa. The investigation consisted of resident interviews, staff interviews, and document review.

For allegation, Licensee did not provide a 60 day written notice of rate increase to a resident's representative:

Interview with the Administrator revealed that Resident R1’s was given a thirty (30) day notice of a rate increase. The rate increase was sent via text message to R1’s responsible party. Document review of R1’s records revealed that the facility did not have a written record of R1’s rate increase.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
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 5
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
04/30/2021 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210430143456

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: 3DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mercillina AjunwaTIME COMPLETED:
11:42 AM
ALLEGATION(S):
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A resident's heart monitor was not connected to WIFI for medical monitoring.
Facility staff are not meeting resident's hygiene needs.
Licensee would not provide a resident’s representative with a copy of the admission agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to investigate and deliver findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Administrator Mercillina Ajunwa. The investigation consisted of resident interviews, staff interviews, and document review.

For allegation, A resident's heart monitor was not connected to WIFI for medical monitoring:

Interview with Administrator revealed Resident R1’s heart monitor was connected to the facilities WIFI. There were times when R1 would unplug the heart monitor. The heart monitor would beep, and a light would appear when it was unplugged. The staff would immediately plug the heart monitor back in when they heard the beeping and saw the light flashing. Document review of R1’s records did not indicate that their heart monitor was not connected to the facilities WIFI. LPA was not able to interview R1 due to R1 passing away.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20210430143456
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: 10/25/2023
NARRATIVE
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For allegation, Facility staff are not meeting resident's hygiene needs:

Interviews with the Administrator and the residents revealed that the resident’s hygiene needs are being met by the staff. The staff denied neglecting the resident’s hygiene needs. The facility staff assists with hygiene care such as bathing, grooming, changing clothing, and incontinence care. The residents are bathed based on their individual bathing schedule. The resident’s diapers are checked every two (2) hours by the staff. If a resident needs additional diaper changes, it is done as needed. The residents are groomed when they are showered as well as when needed. The residents clothing is changed daily and or as needed.

For allegation, Licensee would not provide a resident’s representative with a copy of the admission agreement:

Interviews with the Administrator and R1’s responsible party revealed that R1’s responsible party was given a copy of the admissions agreement.

Overall, there was not enough evidence to collaborate the allegations listed above.

Based on evidence obtained during the investigation, the three (3) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

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 (LIC9099) was discussed and provided to Administrator Mercillina Ajunwa, 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: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20210430143456
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: 10/25/2023
NARRATIVE
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Based on evidence obtained during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because of the preponderance of evidence the standard has been met.

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 (LIC9099) and LIC9099D were discussed and provided to Administrator Mercillina Ajunwa, 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: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20210430143456
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2023
Section Cited
HSC
1569.655(a)
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HSC1569.655 (a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. This subdivision shall not apply to optional services that are provided by individuals, professionals, or organizations under a separate fee-for-service arrangement with residents.
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The licensee has agreed to read health and safety code 1569.655 entirely and send LPA a self-certified letter that the code was read and understood. The licensee has agreed to provide a sixty (60) day written notice to all residents moving forward when there is a rate increase. POC is due by 10/30/2023.
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Based on interview and record review, the licensee did not comply with the section cited above evidenced by not providing the resident with a sixty (60) notice of rate increase which poses a potential health, safety, or personal rights risk to persons 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) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5