Inspection Reports for Mercy McMahon Terrace
3865 J St, Sacramento, CA 95816, CA, 95816
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with several complaint investigations unsubstantiated, indicating generally good compliance over time. However, some substantiated complaints involved staff rough handling residents, resulting in immediate health and safety risks and an immediate civil penalty issued in September 2022. The most recent report from December 26, 2024, cited a deficiency for an unlocked medication cart accessible to a resident who should not self-administer medications, posing an immediate risk. Another substantiated complaint that same day involved a staff member’s rough handling of a resident, leading to termination. While the facility has addressed many issues with staff training and follow-up, the pattern of occasional personal rights and medication management concerns suggests some ongoing areas for attention.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 117
Capacity: 189
Deficiencies: 1
Dec 26, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted by Licensing Program Analysts Kevin Gould and Holly Williams to evaluate compliance with regulations at Mercy McMahon Terrace facility.
Findings
The inspection found that the facility generally met environmental and safety standards, including adequate furnishings, proper temperature controls, and secured storage for medications and hazardous materials. However, a deficiency was cited for an unlocked medication cart accessible to a resident who was not allowed to self-administer medications, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident whose medical assessment stated they could not handle prescription medications had access to an unlocked medication cart, posing an immediate health, safety, or personal rights risk. | Type A |
Report Facts
Resident files reviewed: 7
Staff files reviewed: 7
Staff interviewed: 2
Residents interviewed: 2
Plan of Correction Due Date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Erickson | Facility Administrator | Met with Licensing Program Analysts during inspection and removed unlocked spray paint from craft room |
| Kevin Gould | Licensing Program Analyst | Conducted the annual inspection |
| Holly Williams | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervised the inspection and signed the report |
Inspection Report
Complaint Investigation
Census: 117
Capacity: 189
Deficiencies: 1
Dec 26, 2024
Visit Reason
The visit was an unannounced case management inspection conducted to investigate allegations of staff mishandling a resident.
Findings
The investigation found that staff member S13 aggressively wiped a resident's face and neck and failed to change the resident's soiled diaper for at least two hours despite reminders from other staff. The facility terminated S13 based on multiple witness accounts.
Complaint Details
The complaint was substantiated based on interviews with three staff members and the victim resident confirming the allegations against staff member S13.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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 staff member S13 handling a resident in a rough manner posing an immediate health, safety and/or personnel rights risk. | Type A |
Report Facts
Capacity: 189
Census: 117
Plan of Correction Due Date: Dec 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Erickson | Administrator | Facility administrator met with LPAs and was involved in the exit interview |
| Kevin Gould | Licensing Program Analyst | Conducted the inspection along with Holly Williams |
| Holly Williams | Licensing Program Analyst | Conducted the inspection and created the report |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 189
Deficiencies: 0
Oct 3, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-08-26 regarding unsafe accommodations and insufficient staffing at the facility.
Findings
The investigation found insufficient evidence to substantiate the allegations. The facility was observed to be clean and well maintained, and most residents and staff reported that resident needs were met and staffing was sufficient.
Complaint Details
The complaint was unsubstantiated. Allegations included unsafe, unhealthful, and uncomfortable accommodations and insufficient staffing to meet resident needs. Interviews and observations did not support these claims.
Report Facts
Resident interviews: 8
Residents stating needs met: 6
Staff interviews: 10
Staff stating timely response: 7
Response time expectation: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation and exit interview |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation |
| Giam Alviedo | Director of Care | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 189
Deficiencies: 0
Dec 29, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff discarded a resident’s personal items without authorization.
Findings
The investigation found that the allegations could not be substantiated based on interviews and statements. The issue was due to a miscommunication between the former resident and the facility, and the facility is implementing new systems to retain resident belongings left behind. No deficiencies were cited.
Complaint Details
The complaint was unsubstantiated. The resident admitted to moving all items out prior to the scheduled move-out day and was satisfied with the facility's resolution, including prorated charges and a refund. The department determined there was insufficient evidence to prove the alleged violation occurred.
Report Facts
Capacity: 189
Census: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation |
| Mary Erickson | Administrator | Facility administrator present during exit interview |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 189
Deficiencies: 0
Dec 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-11-29 regarding resident room security, planned activities, lighting, feeding assistance, and resident leaving the facility with assistance.
Findings
All allegations were found to be unsubstantiated after facility tours, interviews with staff and residents, and document reviews. The facility was observed to have unlocked resident room doors with appropriate egress systems, planned activities were offered and inclusive, lighting was sufficient, feeding assistance was provided as needed, and the facility attempted to assist a resident with leaving the facility but was limited by health and safety concerns.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included unlocked resident rooms, lack of planned activities, insufficient lighting, inadequate feeding assistance, and failure to assist a resident leaving the facility. Evidence did not support these allegations.
Report Facts
Capacity: 189
Census: 97
Complaint Control Number: 27-AS-20231129082707
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Ivey-Canady | Licensing Program Analyst | Conducted the complaint investigation and facility tours |
| Latrice Ross | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Census: 97
Capacity: 189
Deficiencies: 0
Dec 19, 2023
Visit Reason
The visit was an unannounced case management incident inspection triggered by an incident report dated 12/12/2023 regarding a resident fall.
Findings
The inspection found no deficiencies. Resident 1 fell while trying to enter their apartment using a walker but was sent to the emergency room and returned with no additional orders or pain reported. The facility is conducting fall prevention training for staff.
Report Facts
Incident report date: Dec 12, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Ivey Canady | Licensing Program Analyst | Arrived at facility for unannounced visit regarding incident |
| LaTrice Ross | Acting Administrator | Met with Licensing Program Analyst and involved in incident report |
| Mary Erickson | Administrator | Facility Administrator named in report header |
Inspection Report
Annual Inspection
Census: 97
Capacity: 189
Deficiencies: 0
Dec 19, 2023
Visit Reason
Licensing Program Analyst Jamie Ivey Canady made an unannounced visit to conduct an annual inspection to ensure compliance with Title 22 regulations.
Findings
The facility was found to be in compliance with California Code of Regulations, Title 22 and Health and Safety Code, with no deficiencies cited at this time. The facility was sanitary, had adequate food supply, and resident and staff files were up to date.
Report Facts
Residents licensed ambulatory: 89
Residents licensed non-ambulatory: 100
Hospice waiver residents: 18
Water temperature: 115
Last fire inspection date: Jun 30, 2023
Last fire drill date: Oct 23, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Ivey Canady | Licensing Program Analyst | Conducted the annual inspection visit |
| LaTrice Ross | Facility representative met during inspection | |
| Mary Erickson | Administrator | Facility administrator |
Inspection Report
Follow-Up
Census: 114
Capacity: 189
Deficiencies: 0
Dec 5, 2023
Visit Reason
The visit was an unannounced case management follow-up regarding an incident report received on 2023-11-21 about resident R1 having an unexplained laceration on the left leg.
Findings
No deficiencies were observed during the visit. The facility reported that R1 has recovered and the laceration was a skin tear. Documentation of R1's current condition was reviewed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Ivey Canady | Licensing Program Analyst | Conducted the case management visit and explained the purpose of the visit. |
| LaTrice Ross | Met with the Licensing Program Analyst during the visit. | |
| Mary Erickson | Administrator | Facility administrator who received a copy of the report. |
Inspection Report
Annual Inspection
Census: 110
Capacity: 189
Deficiencies: 0
Jan 25, 2023
Visit Reason
An unannounced annual inspection was conducted to ensure compliance with Title 22 regulations.
Findings
The facility was found to be in compliance with California Code of Regulations, Title 22 and Health and Safety Code, with no deficiencies cited at this time.
Report Facts
Hospice waiver residents: 18
Ambulatory residents capacity: 89
Non-ambulatory residents capacity: 100
Facility water temperature: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the inspection and toured the facility |
| Mary Erickson | Administrator | Facility administrator who met with the Licensing Program Analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 189
Deficiencies: 1
Dec 27, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that staff physically abused a resident and failed to report the resident's condition in a timely manner.
Findings
The investigation found that the allegation of staff not reporting the resident's condition in a timely manner was unsubstantiated. However, the allegation that the resident was roughly handled by facility staff was substantiated, resulting in bruising to the resident. The facility conducted additional staff training on transfers and moving residents. An immediate civil penalty was assessed due to the substantiated finding.
Complaint Details
The complaint was received on 09/14/2022 alleging staff physically abused a resident and failed to report the resident's condition timely. The allegation of physical abuse was substantiated, while the failure to report was unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Based on record reviews and interviews, resident sustained bruising due to staff rough handling, posing an immediate health and safety risk to residents in care. | Type A |
Report Facts
Civil penalty amount: 500
Deficiencies cited: 1
Plan of Correction due date: Jan 31, 2023
Capacity: 189
Census: 111
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Pang Lee | Licensing Program Analyst | Arrived at the facility unannounced to deliver complaint findings. |
| Mary Erickson | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 189
Deficiencies: 1
Oct 12, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-08-29 regarding staff not wearing masks and failure to report COVID cases as required.
Findings
The investigation substantiated that on one occasion a staff member was not wearing a mask during their shift, posing a potential health and safety risk. The facility management addressed the issue with training. The allegation regarding failure to report COVID cases was unsubstantiated as the facility provided required information and statistical data to responsible parties and agencies.
Complaint Details
The complaint investigation was substantiated for staff not wearing masks while on duty. The allegation that the facility administrator was not reporting COVID cases as required was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Based on record review, on one occasion a staff was seen not wearing a mask, posing a potential health and safety risk to residents. | Type B |
Report Facts
Deficiencies cited: 1
Plan of Correction due date: Oct 31, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Mary Erickson | Administrator | Facility administrator involved in investigation and findings |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 189
Deficiencies: 0
May 26, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that residents were being locked out of the facility due to being short staffed.
Findings
The investigation found no evidence to substantiate the allegation. Staff and residents reported no issues with leaving or reentering the facility, and procedures were in place to assist residents. Temporary Sunday entry restrictions had been lifted as of April 2022. The memory care unit doorbell response time averaged one minute, and COVID-19 screening policies were being followed.
Complaint Details
The complaint alleged residents were being locked out of the facility due to short staffing. The allegation was unsubstantiated after investigation.
Report Facts
Capacity: 189
Census: 105
Doorbell response time: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the complaint investigation and facility visit |
| Mary Erickson | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 106
Capacity: 189
Deficiencies: 0
Mar 4, 2022
Visit Reason
An unannounced annual inspection was conducted to ensure compliance with Title 22 regulations and to evaluate the physical plant of the facility.
Findings
The facility was found to be in compliance with California Code of Regulations, Title 22 and Health and Safety Code, with no deficiencies cited. The facility appeared sanitary, implemented COVID-19 safety measures, and had up-to-date employee and resident files.
Report Facts
Hospice waiver residents: 18
Residents receiving hospice services: 8
Ambulatory residents allowed: 89
Non-ambulatory residents allowed: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Erickson | Administrator | Met with Licensing Program Analyst during inspection and reviewed plan of operation |
| Avelina Martinez | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in the exit interview and report |
Inspection Report
Census: 108
Capacity: 189
Deficiencies: 2
Jan 6, 2022
Visit Reason
The visit was an unannounced case management visit conducted to follow up on the facility's Plan Of Operation, which was not approved due to insufficient detail regarding care pricing levels and how care levels are determined.
Findings
The facility's submitted Plan Of Operation lacked a clear description of care levels and point value assignments, failing to meet regulatory requirements. Deficiencies were cited related to the Plan Of Operation and itemized charges, posing potential health and safety risks to residents.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The revised submitted plan of operation did not contain a description for how care levels are determined, or how point values are assigned, posing a potential health and safety risk to residents. | Type B |
| The notice of rate increase did not include a detailed explanation of additional services or an itemization of charges, posing a potential health and safety risk to residents. | Type B |
Report Facts
Capacity: 189
Census: 108
Plan of Correction Due Date: Jan 20, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the case management visit and cited deficiencies |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor overseeing the inspection |
| Dee Aponte | Facility representative met during the visit |
Inspection Report
Census: 108
Capacity: 189
Deficiencies: 0
Dec 29, 2021
Visit Reason
The visit was conducted as a case management follow-up to review the facility's plan of operation and service plan documentation.
Findings
No deficiencies were cited during this unannounced case management visit conducted in response to follow-up on the facility's plan of operation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Erickson | Administrator | Met with Licensing Program Analyst during the visit and provided revised plan of operation. |
| Avelina Martinez | Licensing Program Analyst | Conducted the unannounced case management visit and explained the purpose of the visit. |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 10
Capacity: 189
Deficiencies: 0
Dec 13, 2021
Visit Reason
An unannounced annual inspection was conducted to ensure compliance with Title 22 regulations and assess the physical plant of the facility.
Findings
The facility was found to be in compliance with California Code of Regulations, Title 22 and Health and Safety Code, with no deficiencies cited at this time. The facility appeared sanitary, implemented COVID-19 safety measures, and had an approved mitigation plan.
Report Facts
Hospice waiver capacity: 18
Residents receiving hospice services: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Erickson | Administrator | Met with Licensing Program Analyst during inspection |
| Avelina Martinez | Licensing Program Analyst | Conducted the annual inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report header |
Inspection Report
Census: 107
Capacity: 189
Deficiencies: 0
Dec 13, 2021
Visit Reason
The visit was conducted as a case management visit to review the facility plan of operation and discuss issues on the submitted plan of operation.
Findings
No deficiencies were cited during this visit per Title 22 Regulations, Division.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Erickson | Administrator | Met with Licensing Program Analyst during the visit and discussed the facility plan of operation. |
| Avelina Martinez | Licensing Program Analyst | Conducted the case management visit and explained the purpose of the visit. |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Capacity: 189
Deficiencies: 1
Feb 12, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including staff not properly trained, no one in charge when Administrator is away, and facility not following resident care plan.
Findings
The complaint regarding staff not properly trained was substantiated due to staff failing to wear face coverings properly, posing an immediate health and safety risk. The allegations that no one was in charge when the Administrator was away and that the facility was not following the resident care plan were found to be unsubstantiated.
Complaint Details
The complaint investigation was based on allegations received on 09/09/2020. The substantiated allegation involved staff not properly trained, specifically a facility Director not wearing a mask properly during family tele-visits, confirmed by a screenshot and subsequent COVID-19 positive test of a resident. The unsubstantiated allegations included no one in charge when the Administrator was away and the facility not following the resident care plan regarding hearing aids.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff failed to wear face coverings properly while providing care and supervision, violating government orders and posing an immediate health and safety risk to residents. | Type A |
Report Facts
Facility capacity: 189
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Erickson | Administrator | Named in findings related to complaint investigation and exit interview |
| Jasmine McCrory | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Oversaw the complaint investigation |
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