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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701088
Report Date: 08/29/2023
Date Signed: 08/29/2023 03:52:21 PM

Document Has Been Signed on 08/29/2023 03:52 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:NYKESHA WILKINSFACILITY TYPE:
737
ADDRESS:3511 DELAWARE AVETELEPHONE:
(760) 571-0953
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 4CENSUS: 4DATE:
08/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Ryiesha LevingstonTIME COMPLETED:
04:00 PM
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On 8-29-23 at 2:33pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding reported medication errors. LPAs met with facility manager Ryiesha Levingston and explained the purpose of the visit. LPAs reviewed incident reports dated 8/14/23 and 8/24/23 and conducted a brief interview with facility manager.

Incident #1: On 8-14-23, facility reported to licensing department that an extra dose of Cetirizine medication was given to resident1 (R1) at approximately 8am. This incident occurred on 8-14-23 and reported to R1's physician as well. No adverse side effects were observed by facility staff.

Incident #2: On 8-24-23, facility reported to licensing department that resident2 (R2) was administered an 8:00pm Divalproex medication at 8:00am. This incident occurred on 8-22-23. Facility notified nursing team and monitored for side effects. No adverse side effects were observed by facility staff and R2's physician was notified.

Above incidents were reported to licensing department within regulatory required time frames. Additional medication staff training has since been completed regarding the above incidents.

As a result of today's case management, citations are issued under Title 22, Division 6. A civil penalty in amount of $250 is issued due to repeat violation within a 12-month period. An exit interview was conducted with facility manager and copy of this report was provided to facility manager. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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 08/29/2023 03:52 PM - It Cannot Be Edited


Created By: Michael Bilger On 08/29/2023 at 02:58 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: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2023
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 to ensure completed medication shadowing of all staff handling medications and updated medication training. Training and shadowing dates to be submitted to LPA by POC due date. Proof of completed training and results of shadowing 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 ensure accurate assistance with prescription medication for R1 and R2 during 8-14-23 and 8-22-23 respectively, which posed an immediate health and safety risk to residents in care.
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Type B
09/08/2023
Section Cited
CCR80064(a)(5)

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Administrator Qualifications. (a) The administrator shall have the following qualifications:(5) Ability to direct the work of others, when applicable. This requirement was not met as evidenced by:
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LIcensee and designees to read regulation 80075(b) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and record review, facility staff under the supervision of Administrator and facility manager committed multiple medication errors on 8-14-23 and 8-22-23, after additional medication errors were previously reported. This poses a potential 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: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023


LIC809 (FAS) - (06/04)
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