Mercy Mcmahon Terrace

Type of visit: Required - 1 Year

On January 12, 2026, at 9:45 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Giam Alviedo and Irene Charnell and explained the purpose of today's visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards 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 115 residents who reside at this facility. The facility has an approved hospice waiver for 28. The LPA Martinez toured the facility with Giam Alviedo and Irene Charnell on January 12, 2026 at 11:00 AM. LPA Martinez reviewed ten resident files and ten staff files. LPA Martinez observed the files to maintained and complete. LPA Martinez reviewed two medication administration records, which were complete and maintained. The facility has a medication room, and first aid kit. The facility has an infection control plan and a disaster plan. The last fire drill was on December 12, 2025. The last fire inspection was conducted on April 30, 2025. Facility water temperature measured at 106 degrees, and the facility temperature measured at 73 degrees. Facility common areas, resident bedrooms, and resident bathrooms were furnished and sanitary. The facility kitchen is sanitary, and the facility had an adequate food supply. During today's tour of facility kitchen, LPA Martinez observed a couple of canned foods were expired. A technical violation was given and expired canned foods were removed. Continued... LPA Martinez observed a water feature located at the courtyard. LPA Martinez will follow up on the water feature at a late date. During today's annual inspection, a technical violation was given to the facility. There were deficiencies cited at this annual inspection. An exit interview was held, and a copy of this report was given to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Jan 12, 2026

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, Dec 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Dec 27, 2024

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: 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.the state’s words, verbatim · CDSS document, Dec 26, 2024

Plan of correction: Licensee agrees to conduct training on personnel rights. Please send plan of when training will be and training information by poc due date.

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Dec 26, 2024

Allegation investigated: Licensee does not ensure that resident(s) are provided safe, healthful and comfortable accommodations, furnishings and equipment. Licensee does not ensure that the facility has enough staff to meet the needs of residents in care.

On 10/3/24, Licensing Program Analyst (LPA) Tung Truong conducted unannounced visit to complete and delivery findings for a complaint investigation received on 8/26/24 with the allegations above. LPA met with Director of Care Giam Alviedo and discussed the conclusion for complaint and the findings. Throughout the course of the investigation, LPA Tung Truong and Pang Lee toured the facility and observed bedrooms, kitchen, living area, and laundry area. LPAs conducted interviews with residents and staff and reviewed records. Based on observations, interviews and record reviews, there is insufficient evidence to support the allegations “Licensee does not ensure that resident(s) are provided safe, healthful and comfortable accommodations, furnishings and equipment” LPAs observed the facility is clean and well maintained. Based on resident interviews, 6 out of 8 residents stated that they feel safe and have no concerns with care. Continued on 9099-C Unsubstantiated Regarding the allegation, “Licensee does not ensure that the facility has enough staff to meet the needs of residents in care”, LPA obtained the following information through interviews and records reviews. Based on resident interviews, 6 out of 8 residents stated that their needs were met. Based on staff interviews, 7 out of 10 staff stated that they do respond timely to resident calls and advised that there is sufficient staffing to meet the needs of the residents. It was learned through interviews that the facility is using staffing agency, Clipboard for staff fill-in. According to interviews, it was revealed that the facility is expected for staff to respond to calls within 15 minutes, otherwise an investigative meeting will be held to ensure resident’s needs are tended to timely. As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and a copy of the report was provided upon exit.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 27-AS-20240826100228

Allegation investigated: Personal Rights: Staff discarded resident’s personal items without authorization.

Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Mercy McMahon Terrace on 12/29/23 at 1:30pm to inform the licensee of complaint allegation mentioned above. Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated. LPA conducted interviews with the concerned party (RP) who admitted to moving all items out of the facility prior to her scheduled move out day after providing a 30 day notice to the facility of their intention to move out of the facility. RP states she did return to clean her old room and remove some items from the refrigerator and observed the room had alreadybeen cleaned and had begun to be prepped for a new resident. RP was concerned she would be charged additional fees for cleaning/paining and the return of their alert pendant. RP states she contacted the facility who agreed to prorate the final 30 days and agreed to a refund for the difference to ensure RP's needs were met. RP was satisfied with the outcome and wished to retract the allegation. Unsubstantiated The items discarded were a result of a miscommunication between the former resident and the facility. The facility is putting new systems in place to ensure resident belongings that are left behind are retained for a period of time to ensure residents receive all their belongings when leaving the facility. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of personal rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 29, 2023 · control 27-AS-20231226091951

Allegation investigated: Staff do not ensure residents rooms are to remain unlocked at all times Staff do not ensure planned activities are offered to residents in care Staff do not ensure sufficient lighting is provided in residents rooms Staff do not ensure feeding assistance is provided to residents in care Staff did not ensure resident was allowed to leave the facility with assistance

Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint findings, LPA met with administrator LaTrice Ross and explained the purpose of the visit. LPA Ivey Canady requested, received and reviewed the following facility documents: Administrator personnel file, LIC308, updated LIC500, R1 Preliminary Death Report, R1 resident facility file, LPA Ivey Canady performed interviews with facility residents, witnesses and staff. The Department has determined the following as it relates to the allegations: Staff do not ensure residents rooms are to remain unlocked at all times, Staff do not ensure planned activities are offered to residents in care, Staff do not ensure sufficient lighting is provided in residents rooms, Staff do not ensure feeding assistance is provided to residents in care, Staff did not ensure resident was allowed to leave the facility with assistance Cont 9099-C Unsubstantiated On 11/30/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an unaccompanied facility tour regarding current facility complaint allegations. LPA observed the facility doors to be unlocked with an accompanied egress system on the assisted living and memory care floor of the facility. According to interviews with facility staff and facility residents, there have been no issues with access to the doors to the resident rooms in the facility. Based on facility file review, facility doors remain unlocked throughout the facility and after hours the doors are locked from the inside with signage of instructions for visitors to access the facility. Therefore the allegation, Staff do not ensure are to remain unlocked at all times is unsubstantiated. An unsubstantiated finding means 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, therefore the allegation is UNSUBSTANTIATED. On 12/05/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an unaccompanied facility tour regarding current facility complaint allegations. LPA observed residents exercising in the facility. LPA inquired and it was learned the activity was called "Exercise with Tami" session. LPA requested and received an activity itinerary for the month of December. According to review of the activity log, and the date and time LPA was in the facility, the activity was being performed as scheduled. Based on interviews with R1, R2 and R3, facility activities are a normal occurrence and a welcome feature of being a part of the facility community. Based on interviews with facility staff, all residents are included in the activities, the bedridden residents are included by 1:1 time with facility activity coordinator for book readings and exercises. Therefore the allegation, Staff do not ensure planned activities are offered to residents in care is unsubstantiated. An unsubstantiated finding means 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, therefore the allegation is UNSUBSTANTIATED. On 11/30/2023 and 12/05/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an unaccompanied facility tour regarding current facility complaint allegations. LPA observed all facility lighting to be working and functioning. Based on interviews with facility staff there has been no electrical service interruptions at the facility. According to interviews with facility residents, there are no issues with lights working in individual rooms, hallways or shared facility areas. Therefore the allegation, Staff do not ensure sufficient lighting is provided in resident rooms is unsubstantiated. An unsubstantiated finding means 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, therefore the allegation is UNSUBSTANTIATED. Cont 9099-C On 11/30/2023 and 12/05/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an unaccompanied facility tour regarding current facility complaint allegations. LPA observed facility staff and residents during breakfast and lunch meal services. LPA observed independent residents going into the dining area, seating themselves and feeding themselves. LPA observed facility staff assisting with meals. According to facility staff interviews, bedridden residents are assisted with meals by taking meals to their apartments. It was learned that facility staff sit and assist residents with feedings as needed. LPA observed the residents who could not use their hands being assisted with hand feedings. Based on facility file review, meal plans are based on dietary medical instructions. According to staff interviews, before the dining services are over for breakfast lunch and dinner, a check list is conducted and caregivers go apartment by apartment and ask if assistance is needed. According to facility resident interviews, there are no complaints regarding facility meal services. Therefore, based on facility interviews, facility file reviews and LPA observation the allegation Staff do not ensure feeding assistance is provided to residents in care is unsubstantiated. An unsubstantiated finding means 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, therefore the allegation is UNSUBSTANTIATED. Cont 9099-C On 12/05/2023 and 12/19/2023, Licensing Program Analyst (LPA) Jamie Ivey Canady conducted interviews regarding current facility allegations. According to facility staff interviews, on 11/23/2023 R1's family attempted to retrieve R1 from the facility to enjoy a family holiday meal in R1's family home. Based on staff interviews, R1 was weaker than normal on 11/23/2023. Based on facility chart review, R1 needed 2 person assist to get R1 out of the bed on 11/23/2023. According to staff interviews, on 11/23/2023, R1 was too weak to get into the transportation provided by R1's family. It was learned that facility staff exercised every method possible within Title 22 Health and Safety guidelines to assist R1 into the transportation provided by R1's family. Based on witness interviews, R1's family decided it was too costly to pay for a smaller, lower vehicle car service to transport R1 off of facility grounds. Based on facility staff interviews, R1's family did not request the services of the facility transportation vehicles, because the family destination was over 30 miles from the facility. According to facility file review, facility offers transportation within a 10 mile radius of the facility. Based on facility interviews, facility file reviews and interviews with witnesses, facility did attempt to assist R1 with boarding transportation for an out of residency visit with R1's family. Due to the health and safety of R1, facility was unable to assist further with getting R1 into the vehicle provided by R1s family. Therefore the allegation, Staff did not ensure resident was allowed to leave the facility with assistance is unsubstantiated. An unsubstantiated finding means 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, therefore the allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, no deficiencies cited. Exit interview was held and a copy of report was given to acting facility administrator.the state’s words, verbatim · CDSS document, Dec 19, 2023 · control 27-AS-20231129082707

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced regarding the incident report dated 12/12/2023 submitted to the Department. LPA Ivey Canady met with acting administrator Latrice Ross and explained the purpose of today's visit. Community Care Licensing (CCL) received an incident report regarding Resident 1 (R1) having been discovered on the floor by facility staff. Administrator stated care staff saw R1 on the floor. R1 was trying to get into R1's apartment and could not make it. R1 was walking with a walker and R1 loss balance and fell to the floor. R1 was unable to control the walker which resulted in the fall. R1 was sent to the emergency room by facility director of care and accessed by hospital physician. According to interview with facility staff, R1 was sent back to the facility with no additional orders with no reports of pain. Based on facility staff, R1 is currently continuing normal facility routines and activities. Based on interview with facility acting administrator, R1 is an independent resident, free to enter and exit at will, and was exiting the elevator when fall occurred. No care staff witnessed the fall, yet were alerted immediately by facility housekeeper. Facility administrator is conducting an in-service training with facility care staff regarding fall prevention on 1/08/2023. Per California Code of Regulations, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left for acting administrator Latrice Ross.the state’s words, verbatim · CDSS document, Dec 19, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jamie Ivey Canady made an unannounced visit to this facility to conduct an annual inspection. LPA Ivey Canady met with Latrice Ross 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 97 residents who reside at this facility. The facility has an approved hospice waiver. The hospice waiver is for 18 residents. LPA Martinez toured the facility with Latrice Ross admin certificate #6067496740 expires 9/17/2025. The facility has spaced out the common facility furniture, and the facility is sanitary. The facility last fire inspection was on 6/30/2023, and the last fire drill was in 10/23/2023. The facility water temperature measured at 115 degrees. LPA Ivey Canady reviewed resident and staff files, and files were up to date. In addition, the facility had an adequate food supply with all opened food date stamped in accordance with Title 22 regulations and the facility has a water cooler dispensers throughout the facility. 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.the state’s words, verbatim · CDSS document, Dec 19, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at this facility unannounced to conduct a case management visit. LPA met with Latrice Ross and explained the purpose of the visit. The purpose of the visit today, is to follow up regarding an incident report received from the facility on 11/21/2023. Regarding R1 having an unexplained laceration on the left leg. According to facility staff, R1 has recovered and the laceration was a skin tear. LPA requested and received current facility chart notes regarding R1 to include documentation of current status of R1 condition. No deficiencies were observed in accordance with Title 22 California Code of Regulations, and California Health and Safety Code. An exit interview was conducted, and a copy of this report was given to the facility administrator.the state’s words, verbatim · CDSS document, Dec 5, 2023