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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000008
Report Date: 01/26/2023
Date Signed: 01/27/2023 12:58:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/01/2022 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20221201131440
FACILITY NAME:MERAKI OF SACRAMENTOFACILITY NUMBER:
347000008
ADMINISTRATOR:STIR, ANISIA & IOANFACILITY TYPE:
740
ADDRESS:4941 TYLER STREETTELEPHONE:
(916) 348-9316
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:12CENSUS: 8DATE:
01/26/2023
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Darius Stir, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident was hit by another resident in care.
Resident was left on floor for an extended period of time.
INVESTIGATION FINDINGS:
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On January 26, 2023, at 12pm, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to investigate allegations above. LPA spoke with Darius Stir , Administrator, informed him the reason for the visit.

Prior to the visit, LPA completed the required COVID-19 testing protocols, a daily self-screening questionnaire for symptoms of COVID-19; and completed a facility risK assessment. LPA ensured she applied hand sanitizer before entering the facility and wore a mask for Personal Protective Equipment (PPE).

During todays visit, LPA interviewed the administrator and documented the interview.

Based on LPAs interview with the Administrator who admitted the allgeation were true, the preponderance of evidence standards has been met, therefore, the above allegation(s) is found to be SUBSTANTIATED.
To continue see 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 25-AS-20221201131440
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: MERAKI OF SACRAMENTO
FACILITY NUMBER: 347000008
VISIT DATE: 01/26/2023
NARRATIVE
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Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit. Exit interview held, Appeal Rights discussed, Copy of report given.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 25-AS-20221201131440
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MERAKI OF SACRAMENTO
FACILITY NUMBER: 347000008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2023
Section Cited
CCR
87468.1
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Personal Rights.
Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Licensee/Administrator agree to submit a signed statement that regulation 87468.1 will not ocur in the future and what steps will be taken to ensure it won't happen again.

Plan of correction shall be submitted no later than February 26, 2023.
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(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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Based on
Type B
CCR
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This requirement was not met as evidendence by: Based on interview with the administrator, he failed to respond to resident's fall and failed to ensure live-in staff responded to resident in a timely manner and phone were on.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7