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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700649
Report Date: 03/12/2025
Date Signed: 03/12/2025 02:08:17 PM

Document Has Been Signed on 03/12/2025 02:08 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/
DIRECTOR:		JORDAN TRACYFACILITY TYPE:
735
ADDRESS:9029 PEAR ORCHARD COURTTELEPHONE:
(916) 609-2424
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 4CENSUS: 3DATE:
03/12/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Program Administrator, Latisha WoodsonTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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On 03/12/25 ,Licensing Program Analyst (LPA) Talwinder Bains arrived at the above to conduct a Case Management visit regarding an incident that occurred on 02/27/25. LPA met with Program Administrator, Latisha Woodson and explained the reason for the visit.

Alta California Regional Center Special Incident Report (SIR) submitted by facility on 02/27/25 to CCL stated that on 2/27/25, around 12:00 pm, staff 1 (S1) administered resident, R1s noon medication. S1 mixed two capsules of Depakote 250 mg with applesauce and handed the bowl to staff 2 (S2). Unaware that the medication had already been mixed by S1, S2 mixed additional two capsules of Depakote 250 mg with applesauce and gave to R1.

Based on incident report, staff interviews, medication record review, it has been concluded that staff gave double dose of Depakote 250mg which was not prescribed by R1s physician. Facility notified R1s physician, CCL, ALTA and other agencies regarding this medication error on 02/27/25.



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: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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 03/12/2025 02:08 PM - It Cannot Be Edited


Created By: Talwinder Bains On 03/12/2025 at 12:38 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: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2025
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 shall provide medication training for all staff regarding medication administration and submit proof to LPA by POC date-03/13/25.
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Based on record review from the facility, it has been concluded that staff administered double dose of Depakote 250mg to resident, R1 on 02/25/25 during noon time, which was not prescribed by R1s physician, which poses an immediate health and safety risk 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: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
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