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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000008
Report Date: 06/07/2024
Date Signed: 06/07/2024 04:37:48 PM


Document Has Been Signed on 06/07/2024 04:37 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:STIR, ANISIA & IOANFACILITY TYPE:
740
ADDRESS:4941 TYLER STREETTELEPHONE:
(916) 348-9316
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:12CENSUS: 9DATE:
06/07/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Samantha TIME COMPLETED:
04:45 PM
NARRATIVE
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On 6/7/24, LPA Kevin Mknelly conducted a plan of correction visit for the citation issued on 5/28/24. LPA met with the house manager and explained the reason for the visit.

The plan of correction has been completed.

When present on 5/28/24, LPA observed and discussed the locking of the facility gates. LPA was not aware of a locked perimeter waiver and fire clearance for locked gates in place.

On 6/6/24, LPA notified Darius Stir via email that a file review was conducted, a locked perimeter waiver was not found and that absent the waiver, the gates may not be locked.

At today's inspection, the gates were again found to be locked.
A regulation violation citation and civil penalties are therefore assessed.

The gates were unlocked while LPA was present.

A copy of this report civil penalties and appeal rights are provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/07/2024 04:37 PM - 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: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2024
Section Cited
CCR
87705(I)(2)

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Care of Persons with Dementia(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:(2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.
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By the POC date of 6/10/24, Licensee will submit a a plan for staffing to address resident wandering and exit seeking behaviors as well as a waiver request if they wish to pursue the necessary clearance for a locked perimeter (See 87705(I) for waiver requirements).
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This requirement was not met based on obervations by LPA on 5/28/24 and 6/7/24.
This posed an immediate risk to residents.
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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: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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