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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800087
Report Date: 02/25/2025
Date Signed: 02/25/2025 05:28:09 PM

Document Has Been Signed on 02/25/2025 05:28 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 HOME 3FACILITY NUMBER:
331800087
ADMINISTRATOR/
DIRECTOR:		AJUNWA, MERCILLINAFACILITY TYPE:
740
ADDRESS:36427 PISTACHIO DRIVETELEPHONE:
(951) 599-0565
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 6CENSUS: 4DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH: Licensee/Administrator Mercillina AjunwaTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 02/25/2025 at 02:15 PM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct the required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there were one (1) staff present, and four (4) residents present. Licensee/Administrator Mercillina Ajunwa was contacted and informed of the visit. Licensee/Administrator Ajunwa arrived during the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Ajunwa.

The facility has 6 bedrooms, in which five (5) bedrooms are designated for residents, and one (1) bedroom's designated for staff, 3 and 1/2 bathrooms, living room, kitchen, dining area, backyard, laundry room and attached garage. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents, one (1) resident may be bedridden. The current census is four (4) residents. The facility has approved hospice waiver for four (4) residents. LPA Brown was accompanied by Staff #2 (S2) 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). The buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. The facility is maintained at a comfortable temperature of 68 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, 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 temperature in the residents/staffs shared bathroom to be at 105.2 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCLD complaint poster, ombudsman poster, labor laws, and the disaster plan were posted in a common area. 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. Medications are kept inside the medication closet ***Continuation in LIC809C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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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 3
FACILITY NUMBER: 331800087
VISIT DATE: 02/25/2025
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near the kitchen inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility. LPA observed the facility have emergency supplies, food and water.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week and a night staff, awake and on duty at night for facility with dementia residents.

Record Review: The facility has updated Liability Insurance and Infection Control Plan maintained at the facility. LPA reviewed four (4) resident files for admission agreements, updated physician reports, pre-placement appraisals, centrally stored medications list, needs and services plans. LPA Brown observed that Resident #2 (R2) Admission Agreement does not have the Licensee/Facility Representative Signature and no signature date. Deficiency will be issued. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA observed Staff #2 (S2) working at the facility with criminal background clearance but S2's criminal background clearance was not transferred to the facility prior to employment on 11/2024. Deficiency will be issued and civil penalty of $500.00 will be assessed today, and will continue to be assessed of $100.00/day until corrected. Medications/MARs records were audited for two (2) residents and appeared to be dispensed and logged appropriately.

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, LIC421BG and Appeal Rights were discussed and provided to Licensee/Administrator Mercillina Ajunwa.

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

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2025 05:28 PM - It Cannot Be Edited


Created By: Melody Brown On 02/25/2025 at 04:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MERCY HOME 3
FACILITY NUMBER: 331800087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 revie], the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2) criminal backgrpund clearance was transferred to the facility proior to employment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Licensee stated to transfer S2 criminal background clearance to the facility and submit proof to LPA Brown by the Plan of Correction (POC) due date.
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 by the Licensee/Facility Representative which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Licensee signed R2 Admission Agreement during the visit. POC cleared.
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 Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
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