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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000008
Report Date: 09/12/2024
Date Signed: 09/12/2024 04:36:43 PM


Document Has Been Signed on 09/12/2024 04:36 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: DATE:
09/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:TIME COMPLETED:
04:45 PM
NARRATIVE
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On 9/12/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with caregiver, Princess Allen . LPA spoke with Darius Stir by phone and reviewed the report contents.

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, on 9/10/24, 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.
During the 9/10/24 visit, staff interviewed could not provide details about how long R1 had been declining, loss of weight nor decreased oral intake. Interview with Administrator described R1 had significantly declined to the extent that Administrator was seeking to establish a new primary care physician with the intent to initiate hospice care services. Administrator also stated that written records were not kept of R1’s decline and records found that R1 had not had regular/ required physician evaluations since 2021 to 8/30/24. R1 had a diagnosis of Dementia. Lastly, the medication review and interview with Administrator found that R1 had their medications refilled on 8/26/24 yet Administrator held all of R1's medications , 8/26/24- 8/31/24, because Administrator was concerned about possible adverse effects given R1’s condition. There was not medication hold issued by a physician.
On 9/10/24, Administrator also stated that they have been operating the home for the licensee and in doing so, are currently leasing the home from the licensee. LPA directed the Administrator to discontinue the lease so that the licensee reestablishes control of property.
Report continued
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
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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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
VISIT DATE: 09/12/2024
NARRATIVE
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On 9/12/24, LPA conducted follow- up interviews with the following:
A Southern CA tele-health service who wrote an LIC 602 physician’s report dated 8/30/24 for R1- a physician’s assistant (PA) conducted the phone evaluation. R1 was unable to participate in the evaluation due to dementia. Height, weight and blood pressure were not assessed. The facility does not have a waiver in place for a non-physician medical profession to conduct and sign the evaluation.

An area health care provider was contacted by Administrator on 8/28/24 to enroll R1 and to establish Hospice Serviced. Hospice services were approved to begin 9/4/24. The provider provided a death certificate that listed: immediate cause of death as (A) advanced dementia, Parkinson’s disease- onset 10 years; underlying cause of A- poor oral intake with a time for “6 mo”; weight loss – “3 m”; and failure to thrive “1 mo”.

LPA contacted a family member contact- R1’s family member described R1’s passing as sudden but not unexpected as R1 had been declining since a 2021 hospitalization. Described the care at the facility as very good- R1 gained weight after admission as R1’s food intake had increased at the home. Family had not seen R1 in “many months”. Family was not informed of R1’s recent decline. Family was notified of R1’s passing by the coroner on 8/31/24.

These findings demonstrate that Administrator, Darius Stir, did not fulfill the duties and responsibilities of administrator, while Samantha Shaw was absent, when Darius Stir did not demonstrate knowledge of the requirements for providing care and supervision appropriate to the residents; nor did he demonstrate knowledge of and ability to conform to the applicable laws, rules and regulations.

Report continued
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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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
VISIT DATE: 09/12/2024
NARRATIVE
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Since the LPA visit of 9/10/24, three residents have been sent for medical care. Administrator will submit incident reports for each within 7 days of resident hospitalization.

LPA observed 6 of 9 residents present. resident care needs appear to be met by 2 caregivers. 3 of 9 residents are currently not present and are at the hospital.

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.
An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility.

As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted.



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: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/12/2024 04:36 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: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2024
Section Cited
CCR
87466

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Observation of the Resident… When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician
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Licensee will submit proof that observation, documentation and physician contact training is completed by Darius Stir by the POC date of 9/13/24.
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and the resident's responsible person, if any.
This requirement was not met based on statements and records that R1 was demonstrating significent decline, changes were not recorded and a physician was not informed timely. This posed and immediate risk to R1
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Type A
09/13/2024
Section Cited
CCR87465(a)(4)

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Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met based on statements and observation that R1's medication was held for 6 days without a physician's hold order. This was an immediate risk to R1
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Licensee will submit proof that all staff who dispense medicaton are scheduled for 6 hours of medication training with training scheduled within 7 days by the POC date of 9/13/24.
Type A
09/13/2024
Section Cited
CCR
87405

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Administrator - Qualifications and Duties(d) The administrator shall have the qualifications specified...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.This requirement was not met based on staements and records. This poses a immediate risks to residents.
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Licensee will
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: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 09/12/2024 04:36 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: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2024
Section Cited
CCR
87465(h)(6)

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Incidental Medical and Dental (h)... medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year.This eas not met based on records. Potential risk to residents
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Licensee will audit and correct all resident centrally stored records and submit completed records for the past 2 months by the POC date of 9/26/24.
Type B
10/03/2024
Section Cited
CCR
87458(b)

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Medical Assessment (b) The medical assessment shall include, but not be limited to: (physical exam, by a physician, is complete, contains height, weight, blood pressure, Tb clearance and prescribed medications). This requirement was not met by statements and records. This posed a potential risk.
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Licensee will submit new LIC 602s for residents who received reports based on telehealth and signed by a physician's assistant by the POC date of 10/3/24.
Type B
09/13/2024
Section Cited
HSC1569.191(b)

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Sale of licensed facility- Except as provided in subdivision (e), the property and business shall not be transferred until the buyer qualifies for a license or provisional license within the appropriate provisions of this chapter. This requirement was not met based on statement that the licensee leased the facility property to another party. This posed a potential risk to residents.
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Licensee will submit a statement that all other leases for the property are rescinded and that the licensee retains control of the property by the POC date of 9/13/24.

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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: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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