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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340312763
Report Date: 02/12/2021
Date Signed: 02/12/2021 06:06:37 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2020 and conducted by Evaluator Jasmine McCrory
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200909162400
FACILITY NAME:MERCY MCMAHON TERRACEFACILITY NUMBER:
340312763
ADMINISTRATOR:MARY ERICKSONFACILITY TYPE:
740
ADDRESS:3865 J STREETTELEPHONE:
(916) 733-6510
CITY:SACRAMENTOSTATE: CAZIP CODE:
95816
CAPACITY:189CENSUS: DATE:
02/12/2021
UNANNOUNCEDTIME BEGAN:
04:58 PM
MET WITH:Mary Erickson, AdministratorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff not properly trained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) McCrory spoke to Facility Administrator (Admin) Mary Erickson to deliver complaint findings over the phone due to COVID-19 and precautionary measures. LPA informed Admin of the purpose of the call. Community Care Licensing (CCL) received the following complaint allegations:
Staff not properly trained.

During the investigation, LPA interviewed facility and hospice staff, relevant parties, and reviewed documentation pertinent to the investigation of the allegations above.

Regarding the allegation of: staff not properly trained
The complaint alleges witnessing facility Director not wearing mask properly during family tele-visits.
(CONT)
 
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
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 5
Control Number 27-AS-20200909162400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MERCY MCMAHON TERRACE
FACILITY NUMBER: 340312763
VISIT DATE: 02/12/2021
NARRATIVE
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On 09/01/2020 LPA McCrory received an email from facility Licensed Vocational Nurse (LVN) stating one resident (R1) tested positive for COVID-19 and was in the hospital and expected to expire. On 09/08/2020 a conference call was held with Administrator (Admin) Mary Erickson, LVN, LPA McCrory, and LPM Munoz. Call consisted of LPM encouraging Personal Protective Equipment (PPE) training, adequate staffing, and effective customer service and communication.

On 09/14/2020 LPA received a screenshot of a zoom call via email. The timestamp of the screenshot shows the date 09/05/2020 and time 12:11:29. In the screenshot are a resident (R2) and a facility staff member (S1). The zoom screenshot was compared to Resident photos on the Resident Roster generated on 09/16/2020 provided by the facility; LPA compared photos and confirmed identity of R2. In the screenshot, S1 is pictured wearing a surgical face mask on top of a black cloth mask. However, both masks are on the chin of S1 and not covering S1’s nose. On 09/18/2020 LPA received communication that R2 tested positive for COVID-19.

On 09/05/2020, facility failed to protect the personal rights of residents in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of residents in care, in that facility staff failed to wear face coverings while providing care and supervision to residents in care, in violation of official government orders requiring the wearing of face coverings while working under specified conditions.


Based on LPA’s observations the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED (S). California Code of regulations, Title 22, Division 2, Chapter 3.2, Article 5, Section 1569.50(a)(3) is being cited on the attached LIC9099D.



An exit interview was conducted with Administrator Mary Erickson and copies of this Complaint Investigation Report will be provided as an email attachment and requested to be returned with original signature via United States Postal.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20200909162400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MERCY MCMAHON TERRACE
FACILITY NUMBER: 340312763
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/12/2021
Section Cited
HSC
1569.50(a)(3)
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(a) The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:
(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.
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Licensee agrees to conduct in staff training to ensure that all staff knows how to properly wear mask to prevent the spread of COVID-19. Licensee to provide documentation scheduling training by Tuesday 02/16/2021.
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This requirement was not met as evidenced by documentation review. LPA observed a photo of staff not properly wearing mask. The Resident in the photo with staff subsequently tested positive for COVID-19.
This was an immediate health and safety risk to residents in care.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2020 and conducted by Evaluator Jasmine McCrory
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200909162400

FACILITY NAME:MERCY MCMAHON TERRACEFACILITY NUMBER:
340312763
ADMINISTRATOR:MARY ERICKSONFACILITY TYPE:
740
ADDRESS:3865 J STREETTELEPHONE:
(916) 733-6510
CITY:SACRAMENTOSTATE: CAZIP CODE:
95816
CAPACITY:189CENSUS: DATE:
02/12/2021
UNANNOUNCEDTIME BEGAN:
04:58 PM
MET WITH:Mary Erickson, AdministratorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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No one in charge when Administrator is away from facility.
Facility not following Resident care plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) McCrory spoke to Facility Administrator (Admin) Mary Erickson to deliver complaint findings over the phone due to COVID-19 and precautionary measures. LPA informed Admin of the purpose of the call. Community Care Licensing (CCL) received the following complaint allegations:
No one in charge when Administrator is away from facility.
Facility not following Resident care plan

During the investigation, LPA interviewed facility and hospice staff, relevant parties, and reviewed documentation pertinent to the investigation of the allegations above.

Regarding the allegation of: Facility not following resident care plan
The complaint alleges that R2 has two pairs of hearing aids and does not have access to hearing aids during family tele-visits.
(CONTINUED)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20200909162400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MERCY MCMAHON TERRACE
FACILITY NUMBER: 340312763
VISIT DATE: 02/12/2021
NARRATIVE
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LPA reviewed screenshot of a zoom call received via email. The timestamp of the screenshot shows the date 09/05/2020 and time 12:11:29. In the screenshot R2 appears to have a hearing aid in the left ear. On 02/12/2021, Staff were interviewed regarding the procedures for assisting with hearing aids.

Regarding the allegation of: No one in charge when Administrator is away from the facility
The complaint alleges that on Sundays there is no Administrator at the facility, and no one substitutes on the Admin’s behalf. On Sunday 09/27/2020 LPA contacted facility and there was no answer on the initial call. The phone tree was used and there was no answer at the Nurse's station. LPA McCrory continued to use phone tree and finally spoke to on duty LVN. On Sunday 02/07/2021, LPA McCrory contacted the facility via phone. No one answered during the initial call and LPA was automatically transferred to the nurse’s station where staff promptly answered the phone. A message was left for the head nurse who was working with residents. LPA received a return call from the Admin. Prior discussions with the Admin indicate facility has a plan in place for calls which include the implementation of a phone tree. When the initial call is not answered there is an option in place to contact the nurse's station. If the nurse in charge is not available, then whomever answers the phone may assist caller.

This agency has investigated the above listed allegations. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED.

An exit interview was conducted with Administrator Mary Erickson and copies of this Complaint Investigation Report will be provided as an email attachment and requested to be returned with original signature via United States Postal.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5