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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000008
Report Date: 12/12/2024
Date Signed: 12/12/2024 01:02:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20241025151136
FACILITY NAME:MERAKI OF SACRAMENTOFACILITY NUMBER:
347000008
ADMINISTRATOR:SHAW-CAMACHO, SAMANTHAFACILITY TYPE:
740
ADDRESS:4941 TYLER STREETTELEPHONE:
(916) 348-9316
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:12CENSUS: 12DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Samantha ShawTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff are not ensuring that resident's incontinence needs are being met.
INVESTIGATION FINDINGS:
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On 12/12/24, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Samantha Shaw, Administrator to deliver complaint findings for the above allegation.

LPA reviewed resident records, facility records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

It was reported by a witness that on 10/25/24 a outside agency came to the facility to assess R1 and found R1 to have been incontinent and have wet bedding. LPA conducted a complaint investigation visit on 10/30/24 and found R1’s room to have a strong smell of urine.
R1 records state that R1 experiences incontinence, has communication deficits, weakness and uses a wheelchair with assistance to transfer. The Appraisal Needs and Services Plan does not identify the incontinence management plan.
Interview with caregiver on 10/30/24 found staff does not have a clear understanding of R1’s pattern of incontinence episodes or to have a clearly defined toileting schedule.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 59-AS-20241025151136
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MERAKI OF SACRAMENTO
FACILITY NUMBER: 347000008
VISIT DATE: 12/12/2024
NARRATIVE
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Administrator, Darius Stir, at the time of the incident, did not consult with the appropriately skilled professional to design a incontinence care program.
LPA also conducted a collateral visit at the facility R1 had relocated to. R1 was found to be out of bed. R1 was clean dry and odor free an R1’s bed/ bedding was odor free.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Samantha Shaw . Copy of this report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20241025151136
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MERAKI OF SACRAMENTO
FACILITY NUMBER: 347000008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2025
Section Cited
CCR
87625(b)(3)
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Managed Incontinence (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by observations and statements. This posed a potential risk to R1.
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Licensee will review all resident files. For those residents determined to have incontinence, licensee will contact the appropriately skilled professional to design incontinence plans. Licensee will submit the plans to CCL by the POC date of 1/10/24.
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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20241025151136

FACILITY NAME:MERAKI OF SACRAMENTOFACILITY NUMBER:
347000008
ADMINISTRATOR:SHAW-CAMACHO, SAMANTHAFACILITY TYPE:
740
ADDRESS:4941 TYLER STREETTELEPHONE:
(916) 348-9316
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:12CENSUS: 12DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Samantha ShawTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff ignored resident's request for assistance.
INVESTIGATION FINDINGS:
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 On 12/12/24, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with xxx xxx.
LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.
LPA conducted interviews and records review. It was found that R1 has chronic pain related to health conditions. Records found that R1 has had regular hospital visits in response to reports of pain.
R1 was sent to the hospital on 10/27/24 where his chronic conditions were treated with no new orders.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview with administrator and report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4