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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800087
Report Date: 09/07/2021
Date Signed: 09/07/2021 02:53:46 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/21/2020 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200921163904
FACILITY NAME:MERCY HOME 3FACILITY NUMBER:
331800087
ADMINISTRATOR:AJUNWA, MERCILLINAFACILITY TYPE:
740
ADDRESS:36427 PISTACHIO DRIVETELEPHONE:
(951) 599-0565
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:6CENSUS: 6DATE:
09/07/2021
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Mercellina AjunwaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff deprived resident of oxygen
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to deliver the findings of the above allegation. LPA Brown met with facility Administrator Mercillina Ajunwa and explained the purpose of today’s visit. The investigation consisted of interviews and a review of Resident 1 (R1) medical records and facility file. Due to R1s passing, LPA Brown was unable to interview R1.

The allegation states staff deprived resident of oxygen. LPA Brown reviewed medical records and interview with R1’s Primary Physician indicated that R1 was on oxygen therapy upon admission but R1 is capable of administering own oxygen without assistance and R1 has total control of when and how often R1 will use the oxygen. Per review of facility’s Worker Training and Instruction Record, it indicates that all facility staff were trained on how to use oxygen and cpap machine in case R1 will need assistance. Per review of Incident Report, it indicated that R1 has low oxygen saturation. Interview with Staff 1 (S1) indicated that R1 was not deprived of oxygen.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
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 18-AS-20200921163904
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MERCY HOME 3
FACILITY NUMBER: 331800087
VISIT DATE: 09/07/2021
NARRATIVE
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S1 reported that after the EMT left on the first 911 call, R1 removed oxygen that time while talking to S1. S1 added that while calling R1’s family, they noticed saliva coming out of R1’s mouth and S1 reported that R1’s oxygen was on and later found out that R1’s family called 911 when the EMT arrived at the facility. EMT noticed that the oxygen tube was not connected to the oxygen equipment. In this situation where R1 often removed oxygen and uses it when needed, it indicated that R1 accidentally disconnected the tube. Interview with S1 revealed that staff accordingly called 911 during the reported medical emergency and S1 reported that R1 was relocated after hospitalization to another facility to address higher need of care.

Based upon the above stated information, the allegation that staff deprived resident of oxygen is UNSUBSTANTIATED. An UNSUBSTANTIATED allegation means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to Ms. Ajunwa.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2