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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002818
Report Date: 07/29/2024
Date Signed: 07/29/2024 01:43:02 PM

Document Has Been Signed on 07/29/2024 01:43 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MERAKEY - OLD 44FACILITY NUMBER:
455002818
ADMINISTRATOR/
DIRECTOR:		SHAW, NATALIEFACILITY TYPE:
738
ADDRESS:21345 OLD 44 ROADTELEPHONE:
(530) 768-7336
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 4CENSUS: 2DATE:
07/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Program Administrator, Ezekial ContrerasTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On July 29, 2024 at approximately 12:45 PM, Licensing Program Analysts (LPAs), Farhaan Sarangi and Sarah Benson arrived unannounced at Merakey - Old 44 for the purpose of conducting a Case Management-Deficiencies Inspection. Upon arrival, LPAs was greeted at the door by Program Administrator, Ezekial Contreras, and was granted a ccess into the facility.

During this Case Management-Deficiencies inspection, LPA reviewed the Medication Administration Record (MAR) for the date of June 4, 2024 and June 5, 2024 and found that medication was given a day later then what the Physician Order stated (See LIC 809D). Also during today's Case Management-Other inspection, LPAs discussed Reporting Requirements as it relates to reporting incidents to the Community Care Licensing (CCL). Program Administrator understood the Reporting Requirements (See LIC 9102-Technical Advisory).

LPAs also discussed an incident report dated for July 29, 2024 and that the facility will follow-up with the appropriate parties and the Responsible Party. Administrator disclosed that additional resources are currently being provided to the client.

LPA requested the following documents:

-Program Plan of Operation/Program Design-Emergency Intervention Plan

Deficiencies are cited from the California Code of Regulations, Title 22, Division 6, Chapter 1 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and emailed to Program Administrator, Ezekial Contreras.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2024
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 07/29/2024 01:43 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 07/29/2024 at 01:04 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 - OLD 44
FACILITY NUMBER: 455002818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2024
Section Cited
CCR
80075(b)

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80075(b)-Health Related Services:

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
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Administrator shall submit an LIC 9098-Self Certification regarding the importance of ensuring that clients are receiving their medications. In addition, Administrator/Licensee shall submit a plan for future compliance to the LPA by July 30, 2024.
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Licensee/Administrator shall provide staff training to staff who administer medication.

POC due date by: July 30, 2024.

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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:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024


LIC809 (FAS) - (06/04)
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