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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000008
Report Date: 10/10/2024
Date Signed: 10/10/2024 04:03:56 PM


Document Has Been Signed on 10/10/2024 04:03 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: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: 10DATE:
10/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ioan "John" StirTIME COMPLETED:
03:00 PM
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 On 5/11/23, Licensing Program Analyst (LPA), Kevin Mknelly, Regional Manager, Alycia Rayner and Licensing Program Manager, Maribeth Senty were present for a Non-compliance Conference via Microsoft Teams today with Licensee Ioan "John" Stir.
On 9/3/24 the department received a death notification for R1. As R1's passing was unexpected, the department conducted case management visits to gather additional information. Following the investigation it was found that R1 had experienced a decline in their health, over several months for which medical care was not sought, R1's physicians report was a year out of date and R'1's medications were held for five(days) without a physician's order.
Topics discussed during this meeting were:
· Administrator qualifications
· Incidental Medical and Dental Care Services violations
· Personal Rights violations
· Licensee oversight
· Reporting/ communication with physicians
· Record keeping
· Timely medical care
· Staff training
· Timely Needs and services plans
· Observation of Resident-change in condition procedures for administrator and staff. (added 10/10/24)

In today's meeting, the licensee agreed to the drafted non-compliance plan as outlined in LIC 9111.
An exit interview was conducted and a copy of this report will be provided to the facility via email. A copy will be signed and returned to CCLD.
This report is delivered via email to Licensee for review and signature.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
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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