340312763-10-12-2022-27-AS-KHOS-CKCS92-20221019134002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340312763
Report Date: 10/12/2022
Date Signed: 10/12/2022 04:00:47 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/29/2022 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220829084718

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: 106	DATE:	10/12/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Mary Erickson		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility Staff do not wear masks while on duty.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 10/12/2022 at 12:45 PM to deliver complaint findings, LPA met with Mary Erickson and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and obtained facility documents. It was learned on one occasion a staff member was not wearing a masks during their shift. Facility management was made aware, and facility management addressed the mask issue and provided training. Moreover, during interviews, it was also learned that care staff have been informed to wear their mask during all shifts.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted, and a copy of this report was provided to the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/29/2022 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220829084718

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:	DATE:	10/12/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Mary Erickson		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility Administrator is not reporting COVID cases as required.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
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9
10
11
12
13

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 10/12/2022 at 12:45 PM to deliver complaint findings, LPA met with Mary Erickson and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and obtained facility documents. It was learned the facility is required to report a resident Covid-19 positive case to their responsible party. Moreover, the facility is also responsible for providing general covid positive information to all responsible parties. However, this does not require the facility to provide Covid-19 statistical data to residents' responsible parties. Furthermore, during this investigation, it was learned Covid-19 statistical data was being reported to various agencies. Also, the facility Administrator occasionally provides Covid-19 statistical recaps on their frequent MMT update email. This information is provided when Covid-19 precautionary measures are being implemented at the facility. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. A exit interview was conducted, and a copy of the report was given.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20220829084718

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/31/2022 Section Cited HSC 1569.58(a)(2)	1 2 3 4 5 6 7	HSC 1569.58(a)(2)Employee Actions: Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.	1 2 3 4 5 6 7	Administrator agrees to conduct donning and doffing training and provide training on facility mask policy to all staff by POC date 10/31/2022.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: based on record review on one occasion a staff was seen not wearing a mask. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC9099 (FAS) - (06/04)

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