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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701088
Report Date: 08/08/2023
Date Signed: 08/08/2023 11:56:41 AM

Document Has Been Signed on 08/08/2023 11:56 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MERAKEY - DELAWAREFACILITY NUMBER:
392701088
ADMINISTRATOR:NYKESHA WILKINSFACILITY TYPE:
737
ADDRESS:3511 DELAWARE AVETELEPHONE:
(760) 571-0953
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 4CENSUS: 4DATE:
08/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Ryiesha LivingstonTIME COMPLETED:
12:10 PM
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On 8-8-23 at 10:05am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding recently reported medication errors and change in Administrator. LPAs met with acting Administrator Ryiesha Livingston and explained the purpose of the visit. LPAs reviewed incident reports dated 8-1-23, 8-2-23, and 8-4-23. LPAs also conducted interview with acting Administrator and requested copies of medication orders for resident1 (R1) and R2.

Based on record reviews and interviews, it was determined that on 7-31-23 a staff administered an 8pm medication to resident1 (R1) at 8am resulting in R1 being underdosed. Additionally it was determined on 8-3-23 that medication for resident2 (R2) was given incorrectly. On the dates 7-30-23, 7-31-23, 8-1-23, and 8-2-23, only one tablet of trazodone was administered to R2 instead of the prescribed 2 tablets resulting in R2 being underdosed. On 8-1-23, based on incident report dated 8-2-23, R2 was not administered the prescribed medication Divalproex 500mg resulting in R2 being underdosed.

Facility staff notified R1 and R2's physician of the medication errors and followed additional instructions given.

Based on record review and interview, it was determined that Administrator of Record Nykesha Wilkins went on leave approximately the end of May. Per applicable regulations, licensee did not produce evidence that sufficient notification was sent to Department of Developmental Services within 30 days of hiring a new interim Administrator.

Based on today's case management, citations are issued under Title 22, Division 6. An exit interview was conducted with Ryiesha Livingston and a copy of this report was reported to Ryiesha Livingston. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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 08/08/2023 11:56 AM - It Cannot Be Edited


Created By: Michael Bilger On 08/08/2023 at 11:07 AM
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: 08/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2023
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 was not met as evidenced by:
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Licensee will ensure the completed staff training of medication assistance including six rights of medication and following physician's orders. Training date to be submitted to LPA by POC due date. Proof of completed training to be sent to LPA no later than 2 weeks after the date of citation issuance.
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Based on record review and interview, licensee did not enusre accurate assistance with prescription medication for R1 and R2 which posed an immediate health and safety risk to residents in care.
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Type B
08/18/2023
Section Cited
CCR80063(a)

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Accountablity. (a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation. This requirement was not met as evidenced by:
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Licensee will read applicable laws and regulation and submit a signed declaration of understanding to LPA by POC due date. Reference: Title 17, Section 59053(e).

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Based on interview and record review, Licensee did not ensure sufficient notification to applicable department regarding change of administrator, which posed a potential health and safety risk to residents in care.
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Licensee will ensure appropriate notification is sent to applicable Department. Copies and send confirmation to be sent to LPA by POC due date.
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: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


LIC809 (FAS) - (06/04)
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