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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701088
Report Date: 12/12/2023
Date Signed: 12/13/2023 08:01:27 AM

Document Has Been Signed on 12/13/2023 08:01 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MERAKEY - DELAWAREFACILITY NUMBER:
392701088
ADMINISTRATOR:RYIESHA LEVINGSTONFACILITY TYPE:
737
ADDRESS:3511 DELAWARE AVETELEPHONE:
(760) 571-0953
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 4CENSUS: 4DATE:
12/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ryiesha Levingston TIME COMPLETED:
03:30 PM
NARRATIVE
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On 12/12/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to this facility to conduct a case management visit. LPA met with Facility Designated Administrator (FDA), Ryiesha Levingston and explained the purpose of the visit.

Current census was 4. A brief interview with FDA Levingston was conducted.
The purpose of this visit was to follow up on an incident that occurred at the facility on 11/30/2023.
On 11/30/2023, the department arrived at the facility to conduct an unannounced visit. During this visit it was observed by the LPA that R1 was exhibiting crisis behavior towards employees. At this time the LPA attempted to leave the facility where they were approached by R1 from behind and hit the LPA on the right side of their face. The LPA fell into an adjacent bush next to the facility where the LPA managed to de-escalate the situation by asking R1 to count forwards to 3. At the time of the incident, it was observed by the LPA that there was no staff who witnessed the incident or outside with the resident at this time. Interviews of staff present at the time of the incident also show that no staff persons came outside to witness the incident nor lend assistance in de-escalating the resident.
A review of R1's Individual Program Plan (IPP) and Individual Behavioral Support Plan (IBSP) conducted in November 2023 was conducted. R1's IBSP states that R1 is currently on a 2:1 support ratio with both staff in line of sight at all times and only one person actively interacting with them at a time. A review of R1's IPP confirms staffing. In addition, based on R1's IPP it stated that when R1 has an assaultive behavior, the facility is to use the Ukeru technique to help de-escalate the situation. The Urkeru technique shall include reassuring words and pads to help block strikes at facility staff.
Based on the observation and record review, per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.Due to printer issues, a copy of this report was provided via email to the Facility Designated Administrator. A read receipt confirms retrieval of the report.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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 12/13/2023 08:01 AM - It Cannot Be Edited


Created By: Arielle Pascua On 12/12/2023 at 12:44 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MERAKEY - DELAWARE
FACILITY NUMBER: 392701088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2023
Section Cited
CCR
89965(j)

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(j) The licensee shall ensure that a direct care staff person shall not implement emergency intervention techniques until they successfully complete the emergency intervention training as required by the facility's applicable licensure type.
This is not met as evidenced by:
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The licensee shall provide a statement of correction and acknowledgement to the LPA by the POC date, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov by 12/19/2023
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The licensee did not ensure that emergency intervention techniques were conducted during the time of the LPAs visit on 11/30/2023. Based on observation and interviews, there were no staff members present at the time of the incident between the LPA and R1. This poses an immediate health, safety and personal rights risks to persons in care.
This poses an immediate health, safety and personal rights risks to persons in care.
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 Information submitted must include attendees, trainers, and information discussed.
Type A
12/13/2023
Section Cited
CCR85165(d)(3)

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(d) The emergency intervention training curriculum shall address, at a minimum, the following: (3) Alternative methods of handling aggressive and assaultive behavior.
This is not met as evidenced by:
The licensee did not ensure that there were alternative methods to address R1s
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The licensee shall provide a statement of correction and acknowledgement to the LPA by the POC date, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov by 12/19/2023.
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behavior at the time of the visit on 11/30/2023. Based on observation during the LPAs visit, R1 was observed to have continuous aggressive and assaulative behavior with staff in which was not de-escalated using alternative techniques. This poses an immediate health, safety and personal rights risks to persons in care.
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Information discuss shall include how to de-escalate the resident once resident is exhibiting assaultive behaviors and staff is unable to reach a blocking pad or evade the resident. What is the plan for staff, when staff or residents or visitors are being physically assaulted.
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:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2023 08:01 AM - It Cannot Be Edited


Created By: Arielle Pascua On 12/12/2023 at 01:18 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MERAKEY - DELAWARE
FACILITY NUMBER: 392701088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2023
Section Cited
CCR
80065(a)

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(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This is not met as evidenced by:
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The licensee shall provide a statement of correction and acknowledgement to the LPA by the POC date, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov by 12/19/2023
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The Licensee did not ensure that the facility maintained R1's staffing ratio of 2:1 at the time of the incident on 11/30/2023. Based on observation, interviews and record review, on 11/30/2023, there were no staff present at the time of the incident between the LPA and R1. Based on R1s IPP it states that the facility shall maintain a 2:1 staffing ratio. This poses an immediate personal rights risks to persons in care.
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 Information submitted must include attendees, trainers, and information discussed on how to maintain correct staffing ratios.

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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:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


LIC809 (FAS) - (06/04)
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