340312763-1-6-2023-27-AS-KHOS-CNNJS9-20230202061759

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340312763
Report Date: 12/27/2022
Date Signed: 01/06/2023 01:43:18 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, 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
09/14/2022 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220914105538

FACILITY NAME:	MERCY MCMAHON TERRACE		FACILITY NUMBER:	340312763
ADMINISTRATOR:	MARY ERICKSON		FACILITY TYPE:	740
ADDRESS:	3865 J STREET		TELEPHONE:	(916) 733-6510
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95816
CAPACITY:	189	CENSUS: 111	DATE:	12/27/2022
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Dee Aponte		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff physically abused resident in care.
Staff did not report resident’s condition in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee arrived at the facility unannounced on 01/06/2022 at 1:15 PM to deliver complaint findings. LPA Martinez met with Dee Aponte and explained the purpose of the visit.

Throughout the course of the investigation, the Department conducted interviews and reviewed documents. Based on the investigation, it was learned facility staff reported resident 1’s (R1) change of condition in a timely manner and addressed the change in condition. In addition, witness 1 (W1) reported no issues with reporting R1’s change in condition. It was also determined R1 was not physically abused by facility staff. W1 also reported they did not believe R1 was physically abused. As a result, there was not enough evidence to meet the preponderance evidence to prove R1 was physically abused by the facility care staff.
Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

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 4

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
09/14/2022 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220914105538

FACILITY NAME:	MERCY MCMAHON TERRACE		FACILITY NUMBER:	340312763
ADMINISTRATOR:	MARY ERICKSON		FACILITY TYPE:	740
ADDRESS:	3865 J STREET		TELEPHONE:	(916) 733-6510
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95816
CAPACITY:	189	CENSUS: 111	DATE:	12/27/2022
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Dee Aponte		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident was roughly handled by facility staff.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee arrived at the facility unannounced on 01/06/2022 at 1:15 PM to deliver complaint findings. LPA Martinez met with Dee Aponte and explained the purpose of the visit.

Throughout the course of the investigation, the Department conducted interviews and reviewed documents. Based on the investigation, it was learned due to R1's weakened state and body contractures, there was no way R1 could self-inflict harm. Moreover, the investigation revealed R1 was pulled and grabbed too hard by facility care staff, which caused R1 to sustain bruising on their body. Furthermore, facility records indicated facility care staff received an additional two days of training on transfers and moving residents after bruising was found on R1’s body. The investigation further revealed that Department was also informed this incident could have been avoided if there was more initial training with new care staff. As a result, the Department determined R1 was rough handled by facility care staff, which resulted in R1 sustaining bruising on their body.
Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20220914105538

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: 12/27/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type A 01/31/2023 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1(a)(1) Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	The facility has conducted additional two hour training on transfers and moving residents in September of 2022. The facility staff also agrees to conduct personal rights by POC Date 01/31/2023
	8 9 10 11 12 13 14	This requirement was not met as evidence by: based on record reviews and interviews, R1 sustained bruising due to staff rough handling them. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20220914105538

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: 12/27/2022

NARRATIVE

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An immediate $500.00 civil penalty shall be assessed on January 06, 2023; based on the allegation: " Resident was roughly handled by facility staff." R1 sustained bruising on their body due to rough handling by care staff, which posed an immediate threat to the Health, Safety, and Personal Rights of R1.
As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, LIC 421, and appeal rights were given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC9099 (FAS) - (06/04)

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