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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002818
Report Date: 05/03/2023
Date Signed: 05/03/2023 04:15:34 PM

Document Has Been Signed on 05/03/2023 04:15 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:MERAKEY - OLD 44FACILITY NUMBER:
455002818
ADMINISTRATOR:WILSON, LAURAFACILITY TYPE:
738
ADDRESS:21345 OLD 44 ROADTELEPHONE:
(530) 768-7336
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 4CENSUS: DATE:
05/03/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Paula Davis, Jolyn McmillanTIME COMPLETED:
11:25 AM
NARRATIVE
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05/03/2023 11:00 AM Licensing Program Analyst (LPA) Sarah Benson and Licensing Program Manager (LPM) Lauren Croker conducted an office meeting with Paula Davis, Regional Director, and JoLyn Mcmillan, Executive Director - Northern California, using Microsoft Teams.

During the meeting reporting requirements were discussed. As a result of this meeting a type B deficiency is being cited on the attached LIC9099-D.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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 05/03/2023 04:15 PM - It Cannot Be Edited


Created By: Sarah Benson On 05/03/2023 at 01:03 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 - OLD 44
FACILITY NUMBER: 455002818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2023
Section Cited
CCR
80061

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80061 Reporting Requirements (a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department. This requirement is not met as evidenced by:
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Licensee agrees to submit all incident reports from the date of January 1,2023 to current and to submit all future incident reports to CCLD via e-fax at (530)282-2393 as required by the department. All facility staff involved in reporting incidents at the facility shall receive training on reporting procedures by 5/15/23. Licensee shall submit signed staff attendance sheet as proof of training.

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Based on interviews and document review it was determined that the licensee has not been submitting incident reports to CCLD as is required by the department. This poses a potential Health and Safety risk to residents in care.

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The proof of correction is to be received by LPA Benson by 05/15/2023.

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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:Lauren Crocker
LICENSING EVALUATOR NAME:Sarah Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
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