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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005275
Report Date: 09/14/2020
Date Signed: 09/14/2020 05:03:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MERRILL GARDENS AT HUNTINGTON BEACHFACILITY NUMBER:
306005275
ADMINISTRATOR:JOHNSON, JILLFACILITY TYPE:
740
ADDRESS:17200 GOLDENWEST STTELEPHONE:
(714) 842-6569
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:150CENSUS: 104DATE:
09/14/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Jill Johnson, AdministratorTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Jenifer Tirre contacted the facility via telephone to commence a health and safety visit in conjunction with a complaint visit via telephone due to COVID-19 and pre-cautionary measures. LPA identified self and discussed the purpose of the visit with Administrator Jill Johnson.

During the visit, LPA Tirre toured the facility via Face Time. LPA observed bedrooms, Kitchen, restrooms, common dining areas, common areas, hallways and Front entrance lobby. LPA observed residents in common areas doing socially distanced bingo activities and in another common dining room area eating snacks. LPA observed and communicated with 4 Residents. All 4 residents appeared to be happy, talkative, neat in appearance and safe. LPA observed staff wearing Personal Protective equipment such as masks and gloves as well as observed staff engaging with residents in professional manner. LPA observed facility to have food supply in kitchen. LPA also observed facility to have posted COVID-19 posters on hand washing, masks and social distancing. No health and safety concerns were noted.

An exit interview was conducted with Administrator Jill Johnson via Face Time and a copy of this report was provided via email. An electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020
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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