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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002818
Report Date: 01/28/2025
Date Signed: 01/28/2025 09:05:17 AM

Document Has Been Signed on 01/28/2025 09:05 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 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: 4DATE:
01/28/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:BCBA, Amanda Smith
Regional Director, Carrie Lustig		TIME VISIT/
INSPECTION COMPLETED:
09:15 AM
NARRATIVE
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On January 28, 2025 at approximately 08:15 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Merakey-Old 44 unannounced for the purpose of conducting a Case Management-Deficiencies inspection. LPA met with BCBA, Amanda Smith. Regional Director arrived 30 minutes later.

On January 14, 2025, Department of Developmental Services (DDS) conducted an onsight evaluation and identified medication that was not ordered for 2 out of 4 clients in care.

On January 8, 2025, an incident report was forwarded to Community Care Licensing Division indicating that there was a medication error that occurred with a client in care. It is noted on the incident report that the alleged staff member did not compare labels on medications with the medication log.

On January 8, 2025, an incident report was forwarded to Community Care Licensing Division indicating that there was a medication was not started on time (See LIC 809D).

LPA educated the Administrator Assistant regarding the importance of dispensing the medications appropriately and as outlined in Title 22 regulation.

No deficiencies were cited during today's Case Management-Incident Inspection. Exit interview was conducted and a copy of this report was signed and given to the Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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 01/28/2025 09:05 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 01/28/2025 at 08:32 AM
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: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2025
Section Cited
CCR
80075(b)

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80075(b): Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by:
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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.
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Based on observation of incident reports dated for January 8, 2025, LPA identified medication errors that occurred at the facility. In addition, DDS identified two medications that were not ordered for 2 out of 4 clients in care which presents an immiedate health, safety and personal rights risk to the clients in care.
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Licensee/Administrator shall provide outside training to staff who administer medication.

POC due date by: February 11, 2025. (extension due to having to retrain all staff from an outside source/vendor)

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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: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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