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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202591
Report Date: 05/28/2024
Date Signed: 05/29/2024 09:42:49 AM

Document Has Been Signed on 05/29/2024 09:42 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MERRILL GARDENS AT MONTEREYFACILITY NUMBER:
275202591
ADMINISTRATOR/
DIRECTOR:		TIFFANEY SANTOROFACILITY TYPE:
740
ADDRESS:200 IRIS CANYON RDTELEPHONE:
(831) 250-0930
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY: 150CENSUS: 110DATE:
05/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Tiffaney Santoro - Executive Director TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 5/28/2024, Licensing Program Analyst (LPA) D. Ayers arrived unannounced to conduct a Required Annual Inspection. LPA met with Executive Director Tiffaney Santoro and announced the purpose of the visit. Administrator Certificate is current with renewal date 6/13/2025.

LPA toured the facility inside and outside. All passageways and exits were clear and free from obstruction. Fire extinguishers had service tags dated within the last year, and the facility sprinkler system had been serviced. Facility staff maintain records of emergency drills, which are conducted monthly. LPA observed a sufficient supply of emergency food and water, which was properly stored. LPA toured the facility kitchen. Kitchen was clean and LPA observed a sufficient supply of perishable and nonperishable foodstuffs, which were stored properly.

Common areas were clean, odor-free, and well-lit. Interior and exterior doors to facility pool area were securely locked. Outdoor areas were free from hazards and provided adequate seating for residents. LPA toured resident bedrooms and bathrooms. Bedrooms were clean and free from odor. Bathrooms were clean, contained secure grab-bars and non-skid mats, and fixtures were functioning properly. LPA reviewed facility emergency disaster plan. LPA reviewed a sample of staff and resident files.

While reviewing resident files, at approximately 1:50pm, LPA observed that two residents, both diagnosed with dementia, did not have an annual medical assessment and reappraisal completed as required by Title 22 regulations. See attached LIC 809-D deficiencies cited in accordance with California Code of Regulations Title 22, Division 6. Administrator was provided with a copy of the report and appeal rights.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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 05/29/2024 09:42 AM - It Cannot Be Edited


Created By: David Ayers On 05/28/2024 at 02:12 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MERRILL GARDENS AT MONTEREY
FACILITY NUMBER: 275202591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 10 resident files reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Executive Director agreed to have facility staff ensure Resident 1 and Resident 2 have appointments for a medical assessment by a physician, which include a reassessment of the residents' dementia care needs.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Chan
LICENSING EVALUATOR NAME:David Ayers
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2024


LIC809 (FAS) - (06/04)
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