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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340312763
Report Date: 12/29/2021
Date Signed: 01/06/2022 08:38:48 AM

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:
12/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:39 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 12/29/21 at
11:39 AM to conduct a case management visit. LPA met with Mary Erickson 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. LPA Martinez was given an revised plan of operation by the facility Administrator. LPA Martinez also discussed service plan documentation with facility staff and the Administrator. As a result, of this visit, no deficiencies were cited per Title 22 Regulations. An exit interview was conducted, and a copy of this report was given to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021
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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