340312763-10-3-2024-27-AS-KHOS-DA4MYS-20241016100202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340312763
Report Date: 10/03/2024
Date Signed: 10/03/2024 12:26:46 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
08/26/2024 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20240826100228

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: 113	DATE:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Giam Alviedo		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Licensee does not ensure that resident(s) are provided safe, healthful and comfortable accommodations, furnishings and equipment.
Licensee does not ensure that the facility has enough staff to meet the needs of residents in care.

INVESTIGATION FINDINGS:

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On 10/3/24, Licensing Program Analyst (LPA) Tung Truong conducted unannounced visit to complete and delivery findings for a complaint investigation received on 8/26/24 with the allegations above. LPA met with Director of Care Giam Alviedo and discussed the conclusion for complaint and the findings.

Throughout the course of the investigation, LPA Tung Truong and Pang Lee toured the facility and observed bedrooms, kitchen, living area, and laundry area. LPAs conducted interviews with residents and staff and reviewed records. Based on observations, interviews and record reviews, there is insufficient evidence to support the allegations “Licensee does not ensure that resident(s) are provided safe, healthful and comfortable accommodations, furnishings and equipment” LPAs observed the facility is clean and well maintained. Based on resident interviews, 6 out of 8 residents stated that they feel safe and have no concerns with care.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240826100228

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: 10/03/2024

NARRATIVE

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Regarding the allegation, “Licensee does not ensure that the facility has enough staff to meet the needs of residents in care”, LPA obtained the following information through interviews and records reviews. Based on resident interviews, 6 out of 8 residents stated that their needs were met. Based on staff interviews, 7 out of 10 staff stated that they do respond timely to resident calls and advised that there is sufficient staffing to meet the needs of the residents. It was learned through interviews that the facility is using staffing agency, Clipboard for staff fill-in. According to interviews, it was revealed that the facility is expected for staff to respond to calls within 15 minutes, otherwise an investigative meeting will be held to ensure resident’s needs are tended to timely.

As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted and a copy of the report was provided upon exit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

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