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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202591
Report Date: 07/17/2024
Date Signed: 07/18/2024 12:45:25 PM


Document Has Been Signed on 07/18/2024 12:45 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:MERRILL GARDENS AT MONTEREYFACILITY NUMBER:
275202591
ADMINISTRATOR:TIFFANEY SANTOROFACILITY TYPE:
740
ADDRESS:200 IRIS CANYON RDTELEPHONE:
(831) 250-0930
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY:150CENSUS: 110DATE:
07/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Adminsitrator, Tiffaney SantoroTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today to conduct a Case Management visit. LPA Hurt met with Administrator Tiffaney Santoro, and explained the purpose of the visit.


The facility reported a medication error that took place on 07/11/2024 at 01:15 p.m. Staff 1 handed Resident 1 a medication that was meant for another resident. Resident 1 was hospitalized due to the medication error, and returned to the community around 02:00 a.m. on 07/12/2024. Staff 1 has since been provided training and removed from the medication technician in training position.

The following Deficiencies are being cited per Title 22 Regulations.

Exit interview conducted with Administrator Tiffaney Santoro, a copy of this report along with appeal rights provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/18/2024 12:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MERRILL GARDENS AT MONTEREY
FACILITY NUMBER: 275202591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2024
Section Cited
CCR
87465(a)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: The following requirement has not been met as evidenced by:
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Administrator will send training on medication administration for Staff 1, and a statement acknowledging removal of staff 1 from medication technication in training position to LPA by 07/18/24 POC date.
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Resident 1 was given incorrect medication on 07/11/2024 resulting in a visit to the hosptial, which poses an immediate health,safety, or personal rights 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.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
LIC809 (FAS) - (06/04)
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