306005275-2-11-2022-22-AS-SSAS-CE9TKV-20220509144835

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005275
Report Date: 02/11/2022
Date Signed: 02/11/2022 02:43:12 PM

Unsubstantiated

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
02/03/2022 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220203134704

FACILITY NAME:	MERRILL GARDENS AT HUNTINGTON BEACH		FACILITY NUMBER:	306005275
ADMINISTRATOR:	JOHNSON, JILL		FACILITY TYPE:	740
ADDRESS:	17200 GOLDENWEST ST		TELEPHONE:	(714) 842-6569
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY:	150	CENSUS: 117	DATE:	02/11/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Jill Johnson - General Manager		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Resident in care was left unattended for an extended period of time

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced initial 10 day complaint visit to investigate the above allegation. LPA Velazquez met with General Manager (GM) Jill Johnson to discuss the allegation.

During today's visit LPA Velazquez reviewed resident, staff, and facility records. LPA Velazquez also conducted interviews with staff and residents. LPA Velazquez also conducted a partial tour of the physical plant with GM Johnson.

During the course of the investigation LPA reviewed facility, staff, and resident records. Records reviewed included resident and staff rosters, staff schedules, resident incident reports, physician's reports, admission agreements, capability evaluations, and progress reports. LPA Velazquez also conducted interviews with staff and residents who were not able to corroborate the above allegation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

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-20220203134704

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: 02/11/2022

NARRATIVE

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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the following allegation: Resident in care was left unattended for an extended period of time is deemed unsubstantiated.

An exit interview was conducted with General Manager Jill Johnson. A copy of this report along with the LIC 811s were provided to General Manager Jill Johnson at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

LIC9099 (FAS) - (06/04)

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