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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317004376
Report Date: 06/19/2023
Date Signed: 06/19/2023 04:08:03 PM

Document Has Been Signed on 06/19/2023 04:08 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MERCY MULTIPLIED AMERICA, INCFACILITY NUMBER:
317004376
ADMINISTRATOR:CINDI HAGENFACILITY TYPE:
735
ADDRESS:1896 MCCLAIN DR.TELEPHONE:
(916) 644-9600
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 40CENSUS: 14DATE:
06/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cindi HagenTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Monday June 19, 2023 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (4) and staff (4) files.

LPA Parks and Administrator Cindi toured the facility together to ensure the health and safety of residents in care. The areas toured included bedrooms, kitchen, common areas, medication room, and backyard. In the areas toured, there were no health or safety violations observed.

Due to time constraints, LPA will complete the annual at a future date. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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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