340312763-12-13-2021-27-AS-AMAZ-C9NS32-20211213123025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 340312763
Report Date: 12/13/2021
Date Signed: 12/13/2021 12:30:31 PM

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 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: 107	DATE:	12/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	Mary Erickson		TIME COMPLETED:	12:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an 2021 annual inspection on 12/13/2021 at 11:00 AM. LPA Martinez will conduct another annual inspection for 2022 next year during the annual required time frame. LPA met with Mary Erickson 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 10 residents who reside at this facility. The facility has an approved hospice waiver. The hospice waiver is for 18 residents, and there are currently 5 residents receiving hospice services.

LPA Martinez toured the facility with Mary Erickson on 12/13/2021 at 11:00 AM.

The facility has submitted a LIC 808 Mitigation Plan. The mitigation plan has been approved. The facility has one central screening area. Residents are allowed to have visitors in their apartments, and all visitors are screened before entering the facility. The facility has Covid-19 postings throughout the facility. The facility appeared to be sanitary. The facility has hand sanitizer throughout the facility. Social distancing practices are being implemented. The facility has spaced out the common facility furniture. The facility is under construction, and the facility has implemented their construction plan. All meals are being served to residents. The facility has a mobile kitchen, which is setup next 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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021

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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