<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202591
Report Date: 05/09/2022
Date Signed: 05/09/2022 04:55:03 PM


Document Has Been Signed on 05/09/2022 04:55 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
CCLD Regional Office, 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: 100DATE:
05/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Administrator Tiffaney SantoroTIME COMPLETED:
05:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst LPA conducted a Case Management to follow up on an incident report. LPA was met by Administrator Tiffaney Santoro and discussed the purpose of the visit.

LPA reviewed records showing that R1 did not receive medication for PM on 4/22/22.

Deficiencies are being cited based on LPA's observation, interviews conducted, and record review in accordance with the CCR Title 22. See LIC 809D.

An exit interview was conducted with Administrator Tiffaney Santoro a copy of this report with Plans of Corrections and appeal rights was provided to Administrator Tiffaney Santoro.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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 05/09/2022 04:55 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MERRILL GARDENS AT MONTEREY
FACILITY NUMBER: 275202591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited

1
2
3
4
5
6
7
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.
8
9
10
11
12
13
14
care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by Licensee did not give R1's precribed medication due to recieving R2's medication which poses an immediate Health, Safety or personal rights risk to the clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2