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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340312763
Report Date: 12/19/2023
Date Signed: 01/29/2024 05:35:52 PM


Document Has Been Signed on 01/29/2024 05:35 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: 97DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:LaTrice RossTIME COMPLETED:
02:19 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady made an unannounced visit to this facility to conduct an annual inspection. LPA Ivey Canady met with Latrice Ross and stated the purpose of today’s visit. LPA inspected the physical plant of the facility to ensure compliance with Title 22 regulations.

The facility is licensed for 189 residents. 89 residents may be ambulatory and 100 residents may be non-ambulatory. There are currently 97 residents who reside at this facility. The facility has an approved hospice waiver. The hospice waiver is for 18 residents.

LPA Martinez toured the facility with Latrice Ross admin certificate #6067496740 expires 9/17/2025.

The facility has spaced out the common facility furniture, and the facility is sanitary. The facility last fire inspection was on 6/30/2023, and the last fire drill was in 10/23/2023. The facility water temperature measured at 115 degrees. LPA Ivey Canady reviewed resident and staff files, and files were up to date. In addition, the facility had an adequate food supply with all opened food date stamped in accordance with Title 22 regulations and the facility has a water cooler dispensers throughout the facility.

The facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.


An exit interview was held, and a copy of this report was given at the end of the visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (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.

LIC809 (FAS) - (06/04)
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