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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002818
Report Date: 04/15/2024
Date Signed: 04/15/2024 01:55:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/26/2024 and conducted by Evaluator Jaynae Boyles
COMPLAINT CONTROL NUMBER: 59-AS-20240126112936
FACILITY NAME:MERAKEY - OLD 44FACILITY NUMBER:
455002818
ADMINISTRATOR:CONTRERAS, EZEKIELFACILITY TYPE:
738
ADDRESS:21345 OLD 44 ROADTELEPHONE:
(530) 768-7336
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:4CENSUS: 4DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Natalia Shaw- Lead II TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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On 04/15/2024, Licensing Program Analyst (LPA) Jaynae Boyles arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 01/26/24. LPA Boyles met with Natalia Shaw, and explained the purpose of the visit.

During the interview process, documents were obtained to include the Physician’s Report, Medication Administrative Records (MARs), Individual Program Plan (IPP) and an internal investigation of the incident.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 59-AS-20240126112936
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MERAKEY - OLD 44
FACILITY NUMBER: 455002818
VISIT DATE: 04/15/2024
NARRATIVE
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During the investigation, the administrator and the staff person involved were interviewed. It was reported that during the month of January 2024, an incident occurred in that a resident (Resident 1) was acting out, trying to run away from the facility and was combative with the staff. It was reported that the resident was acting violent to the staff by hitting, head butting, kicking, and stomping. A staff person (Staff 1) and another staff person tried to implement a two-person standing restraint and provide crisis communication to the resident; however, the resident continued to lash out at the staff. Staff 1 reported that in an effort to have the resident release the other staff person from a grip, Staff 1 put his forearm on the resident's chest and his forearm slipped up to the resident’s throat. Staff 1 advised that he did not intend to have his forearm slip up to the resident's throat; however, it did. The resident indicated that he was choked during the incident. An inappropriate restraint happened, and Staff 1 was let go from his job due to the incident.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 59-AS-20240126112936
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MERAKEY - OLD 44
FACILITY NUMBER: 455002818
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2024
Section Cited
CCR
85102(a)(6)
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85102(a)(6) Emergency Intervention Prohibitions – The following emergency interventions shall not be used on a client: Any manual restraint technique that obstructs a person's airway or impairs or restricts breathing or circulation.

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The administrator agrees to provide a refresher course to staff that are trained in using restraints on a resident. The administrator shall submit proof of training to the licensing agency.
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This requirement was not met as evidenced by: Based on interviews, and records reviewed, the licensee did not ensure that the resident received proper care during a restraint type incident. This poses an immediate risk to residents in care.
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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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3