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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423609
Report Date: 07/23/2024
Date Signed: 07/23/2024 01:56:55 PM


Document Has Been Signed on 07/23/2024 01:56 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:MERCILLINA AJUNWAFACILITY TYPE:
740
ADDRESS:32350 HEARTH GLEN CTTELEPHONE:
(951) 926-0195
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:6CENSUS: 2DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee/Administrator Mercillina AjunwaTIME COMPLETED:
02:15 PM
NARRATIVE
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On 07/23/2024 at 09:00 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA Brown met with a staff and was granted entry to the facility. Licensee/Administrator Mercillina Ajunwa arrived at the facility during the visit. At the time of the visit there were two (2) staff present, and two (two) residents present.

The facility is a five (5) bedroom, three (three) bathroom home with a kitchen/dining area, living room/activity room and a garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility’s approved for three (3) hospice waiver. The current census is two (2) residents. LPA Brown was accompanied by Staff #3 (S3) to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 118 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguisher was also observed at the facility. Posters such as personal rights, the CCLD complaint poster, and the disaster plan were posted in a common area. However, LPA Brown observed bathroom screen window in disrepair. Technical Violation issued.

***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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 21


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
FACILITY NUMBER: 336423609
VISIT DATE: 07/23/2024
NARRATIVE
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Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Room with the resident’s medications locked. LPA Brown observed complete first aid kit and first aid book at the facility.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has an Administrator present during the visit. However, LPA Brown observed no night shift staff scheduled to work at the facility as required for facility with dementia residents. Deficiency will be issued.

Record Review: LPA Brown reviewed two (2) resident files for admission agreements, updated physician reports, and pre-placement appraisals. LPA Brown observed that Resident #2 (R2) Admission Agreement was not signed by both Licensee/Licensee Representative and Resident/Resident Representative. Deficiency will be issued. LPA Brown reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA Brown observed that Staff #1 (S1), Staff #2 (S2) and Staff #3 (S3) do not have cardiopulmonary resuscitation (CPR) training and first aid training. Deficiency will be issued. LPA Brown observed Staff #1 (S1) and Staff #2 (S2) do not have the required Health Screening Report in their file. Deficiency will be issued. LPA Brown observed Staff #1 (S1) and Staff #2 (S2) do not have Tuberculosis (TB) Test and TB Test result in their file. Deficiency will be issued. LPA Brown observed Staff #2 (S2) working at the facility but S2's criminal background clearance was not transferred to the facility prior to employment on 08/2022. Deficiency will be issued and Civil Penalties was assessed during the facility visit today with the amount of $500.00 for S2 will continue to be assessed of $100.00 per day per citation until corrected for not transferring S2 criminal record clearance prior to employment to the facility. Furthermore, Medications/Medication Administration Record (MAR) were audited, and LPA Brown observed that Staff #3 (S3) did not update Resident #2 (R2) MAR after dispensing R2's medication. Deficiency will be issued.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D forms, LIC9102 TA Advisory Notes, LIC421BG and Appeal Rights were discussed and provided to Licensee/Administrator Mercillina Ajunwa.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 21
Document Has Been Signed on 07/23/2024 01:56 PM - 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
FACILITY NUMBER: 336423609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #1 (S1), and Staff #2 (S2) complete the required Tuberculosis (TB) Test which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee stated to submit proof of medical appointment for S1 and S2 to complete the required TB Test to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #1 (S1), Staff #2 (S2) and Staff #3 (S3)eceive the appropriate training in first aid from persons qualified by such agencies as the American Red Cross which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee stated to submit proof of S1, S2 and S3 proof of enrollment on CPR/First Aid Training or proof of completed CPR/First Aid whichever is available to LPA Brown on POC due date.
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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 21


Document Has Been Signed on 07/23/2024 01:56 PM - 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
FACILITY NUMBER: 336423609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not updating Resident #2 (R2) Medication Administration Record (MAR) after dispensing R2's medication per R2's physician direction which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee state to train all staff on CCR 87465(c)(2) and submit proof of all staff training log to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87705(c)(4)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that there's a night staff, that's awake and on duty as required for facility with dementia residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee stated to submit updated Personnel Report (LIC500) and updated Staff Schedule showing a staff scheduled to work night shift as required to LPA Brown on POC due date.
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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 21


Document Has Been Signed on 07/23/2024 01:56 PM - 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
FACILITY NUMBER: 336423609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not developing the Infection Control Plan as required which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
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Licensee stated to submit the required Infection Control Plan to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not transferring Staff #2 (S2) criminal background clearance to the facility prior to employment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
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Licensee stated to transfer S2 criminal background clearance to the facility and submit proof to LPA Brown on Plan of Correction (POC) due date.
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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 5 of 21


Document Has Been Signed on 07/23/2024 01:56 PM - 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
FACILITY NUMBER: 336423609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #2 (R2) Admission Agreement was signed and dated as required by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
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Licensee stated to ensure R2's Admission Agreement was signed was and dated as required by the resident or the resident's representative, if any, and the licensee or the licensee's designated representativeand submit proof to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 6 of 21


Document Has Been Signed on 07/23/2024 01:56 PM - 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
FACILITY NUMBER: 336423609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(11)
87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:


Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above
by not ensuring that Staff #1 (S1) and Staff #2 (S2) complete the required Health Screenig Report which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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2
3
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Licensee stated to submit S1 and S2 Medical Appointment to complete the required Health Screening Report to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 21 of 21