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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700649
Report Date: 08/29/2024
Date Signed: 08/29/2024 10:56:40 AM

Document Has Been Signed on 08/29/2024 10:56 AM - 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/
DIRECTOR:		JORDAN TRACYFACILITY TYPE:
735
ADDRESS:9029 PEAR ORCHARD COURTTELEPHONE:
(916) 609-2424
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 4CENSUS: 3DATE:
08/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Program Administrator, Latisha WoodsonTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) ,Talwinder Bains arrived at the facility unannounced on 08/29/24 to do case management visit and met with Program Administrator, Latisha Woodson and explained the purpose of the visit.

During a facility visit at the facility on 08/27/2024, the Department learned of an incident with R1. Based on the records reviewed and staff’s interviews, it has been determined that the facility did not submit a report incident (SIR) to the Department regarding R1. Information obtained indicated on 08/08/2024, R1 had a change in condition and bruising was found. The facility admitted they failed to follow Title 22 reporting requirements as well as failed to submit an SOC341/ Suspected Physical Abuse.

Additionally, on 08/28/2024, the facility submitted an SIR and SOC341 to the Department regarding missing funds at the facility for resident, R1. Based on the documentation, the incident occurred on 08/17/2024. The facility did not report this incident within the required time frame.

Based on gathered information, it has been concluded that facility did not meet reporting requirements as required per Title 22 §80061(b). Additionally, it has also determined that facility’s administrator did not fulfill their duties as indicated per Title 22 §80064 for Administrator’s Qualifications and Duties.

Based on this information, per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached LIC809-D page.

Exit interview was conducted, copy of this report and appeal rights were provided. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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 08/29/2024 10:56 AM - It Cannot Be Edited


Created By: Talwinder Bains On 08/29/2024 at 10:18 AM
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: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2024
Section Cited
CCR
80061(b)

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80061-(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event…. This requirement is not met as evidenced by;
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Administrator shall send a letter of understanding of this regulation and shall conduct all staff training and will send proof to department within 15 days. Additionally, Administrator shall ensure to send all incidents to department in timely manner and shall keep records for sending those reports.
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Based on documents reviewed, the facility did not meet reporting requirements for incidents that occurred on 08/08/2024 and 08/17/2024 for resident, R1 which poses a potential health and safety risks to residents in care.
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Type B
09/12/2024
Section Cited
CCR80064(a)(3)

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80064-Administrator - Qualifications and Duties-(a)The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation….this requirement is not met as evidenced by;
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Administrator shall send a letter of understanding and shall abide by Administrator’s job and duties per regulation. All POC documents are due by 09/12/24.
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Based on gathered information, the Administrator did not ensure the facility submitted timely and accurate incident reports to the Department as required which poses a potenial health and safety risks to residents in care.
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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: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
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