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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005275
Report Date: 03/30/2021
Date Signed: 03/30/2021 10:50:41 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2020 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20201007154343
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:
03/30/2021
UNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Jill JohnsonTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Facility staff member failed to document administration of a medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman contacted the facility via telephone to deliver findings on the above complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and elements of allegation with Administrator Jill Johnson.
During the course of the investigation, LPA toured the facility, interviewed staff as well as reviewed and obtained pertinent documentation such as medication administration record (MAR) and narcotic sign off sheet. Regarding the allegation that facility staff member failed to document administration of a medication, the investigation revealed the following: On 07/05/2020, Staff 1 (S1) was covering for a call out and passed medications including a narcotic, Norco. On 07/06/2021, S1 observed that the controlled drug record sheet had not been signed for the administration of Norco. S1 verified that the MAR had been signed and then signed the controlled drug record out of sequence. S1 does not pass medications regularly as the staff is in a supervisory position. CONTINUED ON LIC 9099 DATED 03/30/2021.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 22-AS-20201007154343
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 BEACH
FACILITY NUMBER: 306005275
VISIT DATE: 03/30/2021
NARRATIVE
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Community Care Licensing regulations do not require signature on a controlled drug record or use of a MAR during medication administration. Therefore, allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

Exit interview conducted via telephone and a copy of this report was provided to Administrator via email and electronic read receipt confirms document sent.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
LIC9099 (FAS) - (06/04)
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