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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317004376
Report Date: 07/13/2023
Date Signed: 07/13/2023 12:05:13 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/13/2023 12:05 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: 17DATE:
07/13/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Cindi HagenTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday July 13, 2023 to conclude the annual inspection.

During today's annual inspection, LPA Parks finished reviewing resident (4) and staff (4) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023
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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