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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 02:27:20 PM

Document Has Been Signed on 09/27/2022 02:27 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:
01:35 PM
MET WITH:Lashane JoynerTIME COMPLETED:
02:05 PM
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On 9-27-22 at 1:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management due to an incident which occurred on 8-28-22. LPA met with Program Administrator Lashane Joyner and explained the purpose of the visit. LPA interviewed Administrator and reviewed incident report for R1. LPA also reviewed behavioral intervention plan for R1. Based on records reviewed and interviewed, it was determined that R1 engaged in an attempted elopement which resulted in R1 crossing the street and attempting to assault a neighbor. It was further determined that staff observed resident running off the property and were aware of resident's general whereabouts during the incident, and intervened in an attempt to de-escalate incident. Law enforcement was notified as well as licensing department and ombudsman within regulatory time frames. R1 sustained injury and was taken to hospital for treatment, and release same day back to facility. R1's behavioral plan has been updated to reflect behaviors.

Based on 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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