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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000008
Report Date: 12/12/2024
Date Signed: 12/12/2024 01:03:59 PM

Document Has Been Signed on 12/12/2024 01:03 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/
DIRECTOR:		SHAW-CAMACHO, SAMANTHAFACILITY TYPE:
740
ADDRESS:4941 TYLER STREETTELEPHONE:
(916) 348-9316
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY: 12CENSUS: 12DATE:
12/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Samantha ShawTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 12/12/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Samantha Shaw .

On 10/25/24, the department received a complaint regarding care of R1. During the investigation, the following additional deficiencies were found:
R1’s records were incomplete. ID/ Emergency contacts were blank, The Admission Agreement on file was for a facility other that this licensee’s and the medical assessment, the Needs and services plan on file does note clear plans and measurable methods for evaluating how to meet resident needs and on file does not identify the resident’s cognitive impairment.
On 10/25/25, staff interviewed stated that R1 has as needed (PRN) medications for pain. Staff were not able to provide LPA with a copy of the required documentation of PRN medications administered.

As a result of this inspection, the following deficiencies were cited on 809-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. Copy of 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
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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Document Has Been Signed on 12/12/2024 01:03 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 12/12/2024 at 12:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
87506(b)

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Resident Records(b) Each resident’s record shall contain at least the following information: …(8) Names, address, and telephone numbers of the resident’s representative…(15) The admission agreement… This requirement was not met based on records review. This posed a potential risk to R1.
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Licensee will conduct an audit of all current resident records and provide CCLD with a list of resident records reviewed and verification they are complete, current and accurate by the POC date of 1/10/25.
Type B
01/10/2025
Section Cited
CCR
87465(c)(3)

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Incidental Medical and Dental Care(c) (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement was not met based on interview and records review. This posed a potential risk to R1.
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Licensee will conduct an audit of all current resident records and provide CCLD with a list of resident receiving PRN medications and that forms are in place for the required PRN administration docuentation by the POC date of 1/10/25.

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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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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