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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340312763
Report Date: 03/04/2022
Date Signed: 03/04/2022 10:31:12 AM


Document Has Been Signed on 03/04/2022 10:31 AM - 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: 106DATE:
03/04/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mary Erickson TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 03/04/2022 at 9:15 AM. 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 106 residents who reside at this facility. The facility has an approved hospice waiver. The hospice waiver is for 18 residents, and there are currently 8 residents receiving hospice services.

LPA Martinez toured the facility with Mary Erickson on 03/04/2022 at 10:00 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.

LPA Martinez reviewed two employee files and two resident files. Employee and resident files were up to date. LPA inspected a fire extinguisher, and the last inspection was on January of 2022. The facility is sanitary and have snack stations throughout the facility. The facility has water dispensers throughout the facility for resident use. The facility kitchen is under construction, and the facility has implemented their construction plan. The facility has a mobile kitchen, which is setup next the facility. All meals are being served to residents in the facility dinning room. LPA Martinez review plan of operation with Mary Erickson.

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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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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