340312763-12-19-2023-27-AS-KHOS-CZ6JGF-20240104060213

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340312763
Report Date: 12/19/2023
Date Signed: 12/19/2023 02:46:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/29/2023 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20231129082707

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: 97	DATE:	12/19/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Latrice Ross		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff do not ensure residents rooms are to remain unlocked at all times
Staff do not ensure planned activities are offered to residents in care
Staff do not ensure sufficient lighting is provided in residents rooms
Staff do not ensure feeding assistance is provided to residents in care
Staff did not ensure resident was allowed to leave the facility with assistance

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint findings, LPA met with administrator LaTrice Ross and explained the purpose of the visit.

LPA Ivey Canady requested, received and reviewed the following facility documents: Administrator personnel file, LIC308, updated LIC500, R1 Preliminary Death Report, R1 resident facility file, LPA Ivey Canady performed interviews with facility residents, witnesses and staff.

The Department has determined the following as it relates to the allegations: Staff do not ensure residents rooms are to remain unlocked at all times, Staff do not ensure planned activities are offered to residents in care, Staff do not ensure sufficient lighting is provided in residents rooms, Staff do not ensure feeding assistance is provided to residents in care, Staff did not ensure resident was allowed to leave the facility with assistance
Cont 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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

Control Number 27-AS-20231129082707

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MERCY MCMAHON TERRACE	FACILITY NUMBER: 340312763
	VISIT DATE: 12/19/2023

NARRATIVE

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On 11/30/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an unaccompanied facility tour regarding current facility complaint allegations. LPA observed the facility doors to be unlocked with an accompanied egress system on the assisted living and memory care floor of the facility. According to interviews with facility staff and facility residents, there have been no issues with access to the doors to the resident rooms in the facility. Based on facility file review, facility doors remain unlocked throughout the facility and after hours the doors are locked from the inside with signage of instructions for visitors to access the facility. Therefore the allegation, Staff do not ensure are to remain unlocked at all times is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On 12/05/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an unaccompanied facility tour regarding current facility complaint allegations. LPA observed residents exercising in the facility. LPA inquired and it was learned the activity was called "Exercise with Tami" session. LPA requested and received an activity itinerary for the month of December. According to review of the activity log, and the date and time LPA was in the facility, the activity was being performed as scheduled. Based on interviews with R1, R2 and R3, facility activities are a normal occurrence and a welcome feature of being a part of the facility community. Based on interviews with facility staff, all residents are included in the activities, the bedridden residents are included by 1:1 time with facility activity coordinator for book readings and exercises. Therefore the allegation, Staff do not ensure planned activities are offered to residents in care is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On 11/30/2023 and 12/05/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an unaccompanied facility tour regarding current facility complaint allegations. LPA observed all facility lighting to be working and functioning. Based on interviews with facility staff there has been no electrical service interruptions at the facility. According to interviews with facility residents, there are no issues with lights working in individual rooms, hallways or shared facility areas. Therefore the allegation, Staff do not ensure sufficient lighting is provided in resident rooms is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Cont 9099-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20231129082707

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MERCY MCMAHON TERRACE	FACILITY NUMBER: 340312763
	VISIT DATE: 12/19/2023

NARRATIVE

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On 11/30/2023 and 12/05/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an unaccompanied facility tour regarding current facility complaint allegations. LPA observed facility staff and residents during breakfast and lunch meal services. LPA observed independent residents going into the dining area, seating themselves and feeding themselves. LPA observed facility staff assisting with meals. According to facility staff interviews, bedridden residents are assisted with meals by taking meals to their apartments. It was learned that facility staff sit and assist residents with feedings as needed. LPA observed the residents who could not use their hands being assisted with hand feedings. Based on facility file review, meal plans are based on dietary medical instructions. According to staff interviews, before the dining services are over for breakfast lunch and dinner, a check list is conducted and caregivers go apartment by apartment and ask if assistance is needed. According to facility resident interviews, there are no complaints regarding facility meal services. Therefore, based on facility interviews, facility file reviews and LPA observation the allegation Staff do not ensure feeding assistance is provided to residents in care is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Cont 9099-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20231129082707

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MERCY MCMAHON TERRACE	FACILITY NUMBER: 340312763
	VISIT DATE: 12/19/2023

NARRATIVE

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On 12/05/2023 and 12/19/2023, Licensing Program Analyst (LPA) Jamie Ivey Canady conducted interviews regarding current facility allegations. According to facility staff interviews, on 11/23/2023 R1's family attempted to retrieve R1 from the facility to enjoy a family holiday meal in R1's family home. Based on staff interviews, R1 was weaker than normal on 11/23/2023. Based on facility chart review, R1 needed 2 person assist to get R1 out of the bed on 11/23/2023. According to staff interviews, on 11/23/2023, R1 was too weak to get into the transportation provided by R1's family. It was learned that facility staff exercised every method possible within Title 22 Health and Safety guidelines to assist R1 into the transportation provided by R1's family. Based on witness interviews, R1's family decided it was too costly to pay for a smaller, lower vehicle car service to transport R1 off of facility grounds. Based on facility staff interviews, R1's family did not request the services of the facility transportation vehicles, because the family destination was over 30 miles from the facility. According to facility file review, facility offers transportation within a 10 mile radius of the facility. Based on facility interviews, facility file reviews and interviews with witnesses, facility did attempt to assist R1 with boarding transportation for an out of residency visit with R1's family. Due to the health and safety of R1, facility was unable to assist further with getting R1 into the vehicle provided by R1s family. Therefore the allegation, Staff did not ensure resident was allowed to leave the facility with assistance is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Per California Code of Regulations (CCRs) - Title 22, no deficiencies cited. Exit interview was held and a copy of report was given to acting facility administrator.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4