342700650-11-10-2021-25-AS-AHOD-C8N2DM-20211110161834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700650
Report Date: 11/10/2021
Date Signed: 11/10/2021 04:18:40 PM

Document Has Been Signed on 11/10/2021 04:18 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	MERAKEY - PARKS		FACILITY NUMBER:	342700650
ADMINISTRATOR:	MITCHELL, TAYLOR		FACILITY TYPE:	737
ADDRESS:	3333 PARKS LANE		TELEPHONE:	(916) 609-2426
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY: 4		CENSUS: 4	DATE:	11/10/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Chanese Thomas, Administrator		TIME COMPLETED:	03:45 PM

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	Licensing Program Analysts (LPAs) Angela Hood and Michael Hood arrived at the care home today and met with the Administrator, Chanese Thomas. The purpose of today's visit is to conduct a case management visit regarding incident reports received by CCLD. The facility currently does not have any COVID-19 positive cases. LPAs were screened upon entry in the care home and wore N95 masks. All staff wore masks in the facility. On 10/1/21, an incident report was received regarding resident (R1) missing a dose of medication on 9/30/21. Assistant Director contacted facility's RN and R1's physician was contacted as well. According to incident report, there did not appear to be any consequence to R1 as a result of the omission of medication. On 10/11/21, CCLD received an incident report indicating that resident (R2) had a medication omitted by error on 10/9/21 that was discovered on 10/10/21. R2's primary care physician was contacted. The report indicates that there did not appear to be any consequence to R2 as a result of the omission of medication. During today's visit, the Administrator provided two additional incident reports that were emailed to the previously assigned LPA. On 9/17/21, it was identified by facility staff that R2 had a missed medication on 9/16/21. R2's primary care physician and psychiatrist were contacted and both indicated that there were no concerns or follow-up needed regarding the missed medication. On 10/31/21, a medication audit was conducted and facility staff found that R1 missed medication on 10/30/21 in error. Staff members (S1 and S2) involved in the omission of medication were removed from ************************************************Continued on LIC809-C************************************************

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MERAKEY - PARKS	FACILITY NUMBER: 342700650
	VISIT DATE: 11/10/2021

NARRATIVE

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supporting individuals with administration of medication temporarily until further notice. According to the Administrator, the physician was contacted after the incident.

The Administrator provided LPAs with a copy of the medication training attendance sheet with staff signatures. The training was conducted for staff on 9/10/21 and 10/19/21 in an effort to prevent future medication errors at the care home. Administrator stated that the facility conducts an audit on medications nightly.

LPAs conducted a medication count with the Administrator for R1 and R2. All medications were accurate.

Due to the facility self reporting the incidents, providing medication training to staff, as well as removing the 2 staff members responsible for the most recent medication error from providing medications to clients in care in an effort to prevent future medication errors, there are no deficiencies being cited at this time.

Exit interview conducted and a copy of this report was left at the care home.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

LIC809 (FAS) - (06/04)

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