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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 04:07:00 PM

Document Has Been Signed on 12/26/2024 04:07 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:Case Management - DeficienciesUNANNOUNCEDTIME 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 a case management. LPAs Gould and Williams met with facility administrator Mary Erickson and explained the purpose of the visit.

LPAs Gould and Williams reviewed 1 resident files (R7) and interviewed three staff members (S10, S11, S12) and one resident R1.

The incident report states that S13 was aggressively wiping R1's face and neck. S13 was told that R1 had a bowel movement and S13 did not change it for 2 hours. Other staff members S10 and S12 were reminding S13 but S13 did not change R7 for at least two hours. S10 went with S13 to help S13 change R1 and S10 said that R1's diaper was soaked through and feces was all over. Mary Erickson said hat they had enough witnesses that S13 was terminated.

LPAs requested all internal investigation notes to be sent to LPA as the file is currently off site with HR.

This facility is being cited per 22 CCR Section 87468.1(a)(1). An exit interview was held with Mary Erickson. Appeal rights and a copy of this report were left with Erickson.
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 04:07 PM - It Cannot Be Edited


Created By: Holly Williams On 12/26/2024 at 02:36 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/27/2024
Section Cited
CCR
87468.1(a)(1)

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 Personal Rights of Residents in All Facilities. To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by:
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Licensee agrees to conduct training on personnel rights. Please send plan of when training will be and training information by poc due date.
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Based on interviews conducted with three staff members and the victim corroborated the allegations.that staff member S13 handled resident in a rough manner which poses an immediate health, safety and/or personnel rights risk.
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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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