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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340312763
Report Date: 12/13/2021
Date Signed: 12/13/2021 12:29:27 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 TERRACEFACILITY NUMBER:
340312763
ADMINISTRATOR:MARY ERICKSONFACILITY TYPE:
740
ADDRESS:3865 J STREETTELEPHONE:
(916) 733-6510
CITY:SACRAMENTOSTATE: CAZIP CODE:
95816
CAPACITY:189CENSUS: 107DATE:
12/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:59 AM
MET WITH:Mary EricksonTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on 12/13/2021 at 11:00 AM to conduct a case management visit. LPA met with Mary Erickson explained the purpose of the visit.

The purpose of the visit today is in response to review the facility plan of operation and discuss issues on the submitted plan of operation. LPA Martinez requested the revised plan of operation to be submitted to CCLD by 12/20/2021.

LPA Martinez informed Mary Erickson that the revised plan of operation will need to be reviewed and approval by the Department.

As a result, of this visit, no deficiencies were cited per Title 22 Regulations, Division

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (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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