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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000008
Report Date: 05/28/2024
Date Signed: 06/10/2024 08:41:53 AM


Document Has Been Signed on 06/10/2024 08:41 AM - 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:STIR, ANISIA & IOANFACILITY TYPE:
740
ADDRESS:4941 TYLER STREETTELEPHONE:
(916) 348-9316
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:12CENSUS: 9DATE:
05/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Darius StirTIME COMPLETED:
04:00 PM
NARRATIVE
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 On 5/28/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Darius Stir.
The department received an incident report for an incident involving R1.
On 5/22/24, staff found R1 to be in their bed at 6:30 AM and unresponsive. Emergency services were called and transported R1 to an area hospital. R1 was found to have had a medication overdose and was found to have a different resident's medication bottle in R1's pocket. (At the time of this report the other resident to whom the medication were prescribed has not been identified.
LPA and Darius toured the facility to include, R1's bedroom, staff room location, where keys are kept and the kitchen/ medication areas. By reports, the kitchen was locked and medication cabinet keys were hung in the kitchen. R1 was suspected of accessing the kitchen through a window/ counter between the kitchen and living room.
There were no awake overnight staff on the night of 5/21/24. Live-in staff were present but not alerted to need assistance to residents.
Approximately 2 weeks prior to 5/22/24, R1 was suspected of possible accessing keys and having entered the staff office. The keys were moved to the locked kitchen.

R1 has not yet returned to the home.
Licensee will submit the following records to CCL: R1's LIC 602, Pre-appraisal and LIC 625 currently on file. Licensee will request R1 release hospital records for 5/22/24 emergency and hospitalization.

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
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2024
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 06/10/2024 08:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2024
Section Cited
CCR
87705(c)(4)(A)

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Care of person's with dementia- (A) In addition to requirements...Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal,
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While R1 is away from the home, ON care appears appropriate. Licensee has installed camera's in the home and will update their plan of operations.
Licensee will submit a plan for securing dangerous items and keys to those spaces to include proof of staff training of the plan.
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reappraisal or observation to require awake night supervision.This requireent was not met when R1 demonstrated possible need for ON supervision, it was not put in place and keys were not secured.
This posed an immediate risk to R1.
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The plan of correction will be submitted by 5/31/24.

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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.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2024
LIC809 (FAS) - (06/04)
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