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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005275
Report Date: 10/19/2021
Date Signed: 10/19/2021 01:05:09 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: 123DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Administrator, Jill JohnsonTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted, granted entry into the facility and temperature was checked at Facility by Accushield device upon check in at front desk. LPA explained reason for visit.

During the visit LPA toured the facility with Administrator Jill Johnson. Facility is a three story 121 private apartment facility. There are 123 Residents in care. LPA observed proper covid signage at front entrance of facility. At front receptionist desk there is a check in and temperature Accushield monitor for staff and visitors. Facility has required Department postings.
LPA toured Facility Bistro, Outside Patio,Garden House, Garden House kitchen, Assisted living, Resident rooms, Med Tech Rooms, living room, storage rooms, movie media room and Wellness Center. All Resident rooms observed where within department regulations. All restrooms observed contained soap, toilet paper, and towels. Public restrooms observed to have proper Covid signage. Residents were observed relaxing in the dining room eating, relaxing in bedrooms and doing activities in Wellness center. Facility has operating smoke detectors and fire alarms which LPA observed Last fire inspection paperwork was completed in February 2021. Facility has several fire extinguishers, all which were observed as fully charged. Facility has operational chair lift. Facility has ample supply of PPE. LPA observed facility has emergency food and water supply. Facility has a secured location for resident medication and files. LPA observed residents medications and facility has 30 days supply of medications for Residents. LPA reviewed Residents files during visit. Residents emergency contact information and Physicians reports are current. Facility has several designated visitation areas.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator Jill Johnson and a copy of report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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