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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700649
Report Date: 10/12/2023
Date Signed: 10/12/2023 01:13:54 PM

Document Has Been Signed on 10/12/2023 01:13 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MERAKEY - PEAR ORCHARDFACILITY NUMBER:
342700649
ADMINISTRATOR:DEDICATORIA, NICOLASFACILITY TYPE:
735
ADDRESS:9029 PEAR ORCHARD COURTTELEPHONE:
(916) 609-2424
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 3CENSUS: 3DATE:
10/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Rudy Morgan - DSPTIME COMPLETED:
01:30 PM
NARRATIVE
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On 10/12/23, Licensing Program Analysts (LPAs) Talwinder Bains and Cheyenne Ratajczak arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 07/29/23, 09/28/23 and 09/29/23 . LPAs met with DSP, Rudy Morgan and explained the reason for the visit.
1st incident for 07/29/23-
Alta California Regional Center Special Incident Report submitted by facility on 07/29/23 to CCL stated that resident, R1, did not get Ativan (1mg) as ordered by R1s physician on the morning of 07/29/23. Based on incident report, staff interviews, medication record review, R1 was supposed to receive, Ativan (1mg) but there was no medication available to administer on 07/29/23 as facility ran out of this medication. The facility did not ensure that R1 had at least one week supply so resident would not miss the medication. The Facility administration was made aware of this issue on 07/28/23 in the evening that pharmacy did not deliver the medication. At this time, the pharmacy was closed so the facility could not pick up the medication resulted R1 missed this medication dose on 07/29/23. Facility notified R1s physician, CCL, ALTA and other agencies regarding this medication error on 07/29/23. Per facility’s reports, there were no changes to R1s health due to this med error and R1 was at their baseline. Based on this information, it was determined that the facility did not administer this medication to R1 which poses a immediate health and safety risk to residents in care.
2nd incident for 09/28/23, 09/29/23-
Alta California Regional Center Special Incident Report submitted by facility on 09/29/23 to CCL stated that resident, R2, did not get Metformin 1000 mg as ordered by R2s physician in the evening of 09/28/23 and in the morning of 09/29/23. Based on incident report, staff interviews, medication record review, R2 was supposed to receive Metformin 1000mg but there was no medication available to administer on 09/28/23 and 09/29/23 . Facility did not ensure that resident, R2, had at least one week supply so resident did not miss the medication. Facility administration was made aware about this issue that pharmacy did not refill this medication as there was no refills left and required R2s physician’s orders which resulted R2 missed this medication dose on 09/28/23 and 09/29/23. Facility notified R2s physician, CCL, ALTA and other agencies regarding this medication error on 09/29/23. Per facility’s reports, there were no changes to R2s health due to this med error and R2 was at their baseline. Based on this information, it was determined that the facility did not administer this medication to R2 which poses a immediate health and safety risk to residents in care.
Deficiencies are cited pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D. The report was reviewed, appeal rights and a copy of this report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/12/2023 01:13 PM - It Cannot Be Edited


Created By: Talwinder Bains On 10/12/2023 at 12:46 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: MERAKEY - PEAR ORCHARD
FACILITY NUMBER: 342700649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2023
Section Cited
CCR
80075(b)(5)(B)

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80075 Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
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Licensee/Administrator agreed to submit a self-certification of understanding the regulation ,80075 (b)(5))B) and provide medication training for all staff regarding medication administration including ensuring medications are ordered timely. The licensee shall submit proof to LPA by POC date- 10/13/23.
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Based on record review from the facility, on 07/29/23, 09/28/23 and 09/29/23 facility staff did not give medications for R1,R2 as ordered by R1,R2’s physician, which poses an immediate health and safety risk to residents in care.
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Additionally, the Licensee/Administrator will provide monthly medication training for all staff regarding medication administration and medication ordering. Licensee shall submit proof to the department for next 90 days.


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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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


LIC809 (FAS) - (06/04)
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