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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340312763
Report Date: 12/05/2023
Date Signed: 12/05/2023 03:07:05 PM


Document Has Been Signed on 12/05/2023 03:07 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 114DATE:
12/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:LaTrice RossTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at this facility unannounced to conduct a case management visit. LPA met with Latrice Ross and explained the purpose of the visit.

The purpose of the visit today, is to follow up regarding an incident report received from the facility on 11/21/2023. Regarding R1 having an unexplained laceration on the left leg. According to facility staff, R1 has recovered and the laceration was a skin tear.

LPA requested and received current facility chart notes regarding R1 to include documentation of current status of R1 condition.

No deficiencies were observed in accordance with Title 22 California Code of Regulations, and California Health and Safety Code. An exit interview was conducted, and a copy of this report was given to the facility administrator.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
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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