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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701088
Report Date: 09/27/2022
Date Signed: 09/27/2022 02:28:02 PM

Document Has Been Signed on 09/27/2022 02:28 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MERAKEY - DELAWAREFACILITY NUMBER:
392701088
ADMINISTRATOR:JOYNER, LASHANEFACILITY TYPE:
737
ADDRESS:3511 DELAWARE AVETELEPHONE:
(760) 571-0953
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 4CENSUS: 2DATE:
09/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Lashane JoynerTIME COMPLETED:
02:35 PM
NARRATIVE
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On 9-27-22 at 2:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit based on an incident which occurred on 8-9-22. LPA met with Program Administrator Lashane Joyner and explained the purpose of the visit. LPA reviewed incident report for resident1 (R1) and interviewed Administrator. Based on interview and record review, it was determined that R1 did not receive evening medications as prescribed on 8-9-22.

As a result of today's case management visit, citations are issued under Title 22, Division 6, Chapter 1. An exit interview was conducted with Lashane Joyner and a copy of this report was left with Lashane. Appeal rights explained and to be provided via email.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
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 09/27/2022 02:28 PM - It Cannot Be Edited


Created By: Michael Bilger On 09/27/2022 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MERAKEY - DELAWARE
FACILITY NUMBER: 392701088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2022
Section Cited
CCR
80075(b)

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Health Related Services.(b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
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Licensee will conduct staff training on assistance with self-administration of medication and submit a training date to LPA by POC due date. Licensee to complete staff training within 2 weeks from date of citation issuance and submit proof of completed training to LPA.
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Based on record review and interview, licensee did not ensure R1 receive two evening medications in that facility staff did not assist R1 with prescribed medications on 8-9-22. This posed an immediate health and safety risk to residents in care.
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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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022


LIC809 (FAS) - (06/04)
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