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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340312763
Report Date: 12/26/2024
Date Signed: 12/26/2024 04:08:13 PM

Document Has Been Signed on 12/26/2024 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MERCY MCMAHON TERRACEFACILITY NUMBER:
340312763
ADMINISTRATOR/
DIRECTOR:		MARY ERICKSONFACILITY TYPE:
740
ADDRESS:3865 J STREETTELEPHONE:
(916) 733-6510
CITY:SACRAMENTOSTATE: CAZIP CODE:
95816
CAPACITY: 189CENSUS: 117DATE:
12/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mary EricksonTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Kevin Gould and Holly Williams arrived unannounced to conduct an annual inspection. LPAs Gould and Williams met with facility administrator Mary Erickson and explained the purpose of the visit.

LPAs Gould and Williams reviewed 7 resident files (R1-R7) and 7 staff files (S1-S7).

LPAs Gould and Williams toured the facility with Erickson and inspected common areas, the kitchen, bedrooms, bathrooms, basement, hair salon, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 71 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 107.4 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Williams found medication in R1's room and in the Medical assessment (LIC602) it states the resident is not allowed to administer their own medication, is not allowed to administer prescription medications, is not able to store their own medications. LPAs Gould and Williams observed a medication cart to be unlocked and unattended.

LPA Gould and Williams observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPAs Gould and Williams observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPAs Gould and Williams observed a locked cabinet for the storage of medication. LPAs Gould and Williams observed locked cabinets for the storage of cleaning solutions and knives. LPA Williams observed spray paint in an unlocked cabinet in the craft room and Erickson removed the paint.

LPAs Gould and Williams interviewed 2 staff member (S1-S2) and 2 resident (R2-R3).

Per California Code of Regulations the following deficiencies are cited during today's inspection 87465(h)(2) and a technical advisory. An exit interview was conducted and a copy of this report and appeal rights were left at the facility.


SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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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Document Has Been Signed on 12/26/2024 04:08 PM - It Cannot Be Edited


Created By: Holly Williams On 12/26/2024 at 02:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MERCY MCMAHON TERRACE
FACILITY NUMBER: 340312763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure that resident whose LIC602 medical assessment stated resident could not handle prescriptoion medications and the medication cart was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Licensee agrees to send a plan and date of training with sign in sheet when training is complete by POC due dat. Holly.williams@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Holly Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
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