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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 02:26:20 PM

Document Has Been Signed on 09/27/2022 02:26 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:
01:00 PM
MET WITH:Lashane JoynerTIME COMPLETED:
01:34 PM
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On 9-27-22 at 1:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit related to incident which occurred on 8-11-22. LPA met with program administrator Lashane Joyner and explained the purpose of the visit. LPA interviewed Administrator and reviewed incident report as well as R1's behavioral intervention plan. On 8-11-22, according to incident report resident1 (R1) returned to facility from school with observed bruising to right outer forearm. Based on interview and record review, R1 did not have visible bruising on 8-11-22 prior to departing for school. Additionally, based on interview and record review, R1 has a history of running into walls during behavioral episodes. It was determined that incident was reported to licensing department, ombudsman and local law enforcement within regulatory time frame. Behavioral intervention plan as been updated to reflect R1's behavior.

As a result of today's visit. No deficiencies are cited. An exit interview was conducted with Program Administrator Lashane Joyner and a copy of this report was left with Lashane.
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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