<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700649
Report Date: 12/19/2023
Date Signed: 12/19/2023 10:58:57 AM

Document Has Been Signed on 12/19/2023 10:58 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:DEDICATORIA, NICOLASFACILITY TYPE:
735
ADDRESS:9029 PEAR ORCHARD COURTTELEPHONE:
(916) 609-2424
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 4CENSUS: 3DATE:
12/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:DSP-Rudy Morgan TIME COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/19/23, Licensing Program Analysts (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 12/16/23 for resident (R1) and facility submitted incident report (SIR) and SOC341 on12/18/23 and notified Community Care Licensing (CCLD) and other required agencies. LPA met with DSP, Rudy Morgan and explained the reason for the visit.

SIR and SOC341 stated that there were starches on R1s back and bruises on R1s right arm that appeared to be older bruises which was noticed by staff on 12/16/23 during routine care . Reports stated that the bruises on R1s arm look like fingertips. R1 was nonverbal ,has a Intellectual disability and autism. R1 did not appear to be in pain. R1 ambulates independently. Facility notified this incident to ALTA, R1s physician, responsible party , Adult Protective Services (APS) and other required agencies on 12/18/23 . There were no changes to R1s health due to this incident and they are at their baseline.

During, today's visit, LPA interviewed staff (S1) related to this incident. LPA and S1 checked R1s skin during this visit and did not observe any skin marks, redness or discoloration on R1s back or arms. LPA observed R1 enjoying activities during today's visit.

No deficiencies were observed or cited today.
Exit interview conducted and copy of this report has been provided.







SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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 1