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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340312763
Report Date: 01/06/2022
Date Signed: 01/06/2022 03:16:11 PM

Document Has Been Signed on 01/06/2022 03:16 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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: 108DATE:
01/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Dee AponteTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez and Maja Jensen arrived at this facility unannounced on 01/06/22 at 2:00 PM to conduct a case management visit. LPAs met with Dee Aponte and explained the purpose of the visit.

The purpose of the visit today, is in response to follow up on the facility's Plan Of Operation . The Plan Of Operation that was submitted to Community Care Licensing Department was not approved. LPA Martinez has discussed what information is required in the Plan Of Operation. Under the Appendix A: Other Services & Charges, the care pricing level section does not include a description that clearly establishes the standard tasks for all levels of care. There is no description for how care levels are determined, or how point values are assigned.

LPA Martinez has made several attempts to provide technical assistance and guidance in regards to requirements that must be documented in a Plan of Operation. The recent revisions of the Plan Of Operation fails to provide the requested level of care details needed for accountability.

The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of this report was given to the facility

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2022
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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Document Has Been Signed on 01/06/2022 03:16 PM - It Cannot Be Edited


Created By: Avelina Martinez On 01/06/2022 at 01:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MERCY MCMAHON TERRACE
FACILITY NUMBER: 340312763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2022
Section Cited
CCR
87208(a)(2)

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87208 Plan of Operation: Each facility shall have and maintain a current, written definitive plan of operation...A copy of the Admission Agreement, containing basic and optional services. This requirement was not met as evidence by: Based on observation and record review...
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Facility staff agrees to provide a revised plan of operation that includes a description for how care levels are determined, or how point values are assigned. Facility staff will also provide an admission agreement by POC Date 01/20/2022.
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The revised submitted plan of operation did not contain a description for how care levels are determined, or how point values are assigned. This posed a potential health and safety risk to residents in care.
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Type B
01/20/2022
Section Cited
HSC1569.657(a)

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1569.657(a) Rate increase due to change in level of resident care...The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.
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Facility agrees to provide a revised plan of Operation that includes a description for how care levels are determined, or how point values are assigned in rate increases.
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This requirement was not met as evidence by: Based on observation and record review did include an itemized charger document. This posed a potential 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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2022


LIC809 (FAS) - (06/04)
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