<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000008
Report Date: 09/10/2024
Date Signed: 09/10/2024 03:24:13 PM


Document Has Been Signed on 09/10/2024 03:24 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:
09/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Darius StirTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/10/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with caregivers. The Administrator, Darius Stir, was notified and arrived to assist.

On 9.3.24 the department received a death notification for R1. As R1's passing was unexpected, the department conducted a case management visit to gather additional information.
LPA received resident records, interviewed 2 caregivers and the Administrator.
LPA received contact phone numbers in order to conduct additional interviews.
LPA reviewed R1's medications.

The administrator and LPA discussed issues of observation, documentation and notifications of medical professionals. The Administrator will institute additional procedures at the home.
LPA requested that a LIC 500- Staff Roster and LIC 9020- Resident Roster be submitted by email.

As a result of today’s inspection, no deficiencies are cited at this time.
Report reviewed. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
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 1