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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002818
Report Date: 05/17/2023
Date Signed: 05/17/2023 11:00:24 AM

Document Has Been Signed on 05/17/2023 11:00 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, 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: 3DATE:
05/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Paula DavisTIME COMPLETED:
11:10 AM
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LPA Hiratsuka, conducted this visit in response to an incident report submitted to Community Care Licensing on 05/11/2023. It involved an incident between a resident and a staff member. Today LPA learned the facility is still investigating. The facility staff will also keep Community Care Licensing updated on the incident. LPA interviewed the resident and the resident stated they are fine.

At this time there are no deficiencies cited.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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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