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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 01:13:07 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Rudy Morgan - DSPTIME COMPLETED:
01:30 PM
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On 10/12/23, Licensing Program Analyst (LPAs) Talwinder Bains and Cheyenne Ratajczak arrived unannounced to conduct a required annual inspection. LPA met with staff, DSP. Rudy Morgan and explained purpose of inspection. LPA observed all 3 clients in the facility during today's visit.

LPAs and DSP toured the interior and exterior of the facility including the common areas, client bedrooms, client bathrooms, kitchen, laundry area/garage. LPAs observed the home to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. LPAs observed various Covid posters throughout as well as other required postings, including House Rules and personal rights. Inside temperature was observed to be 72* F. Fire extinguisher last serviced 05/01/23. Facility conducts monthly fire and disaster drills, at different hours of the day. The facility has a large back yard area with seating. There are no pools/ponds. LPAs observed locked toxins in the laundry area and locked medications in a separate cabinet. LPAs observed sufficient 2+day perishable/7+day non-perishable food and sufficient PPE on hand. LPAs observed paper towels, soap, sanitizer, trash cans and hand-washing posters in the bathroom. Water temperature measured 108*degree F in the kitchen. Smoke/monoxide alarms were in working order. Games/activities observed on site.

LPAs reviewed (2) client files and (2) staff files and found the required documentation on file, including staff training. LPA reviewed medications for (2) clients and found no errors.

LPAs requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by 10/31/23.

No deficiencies were observed or cited today. Exit interview conducted. A copy of this report was printed and given to DSP.
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)
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