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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005275
Report Date: 10/03/2022
Date Signed: 10/03/2022 03:33:55 PM


Document Has Been Signed on 10/03/2022 03:33 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, 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: 126DATE:
10/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator, Jill JohnsonTIME COMPLETED:
03:50 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 by Accushield device upon check in at front desk. LPA explained reason for visit.

LPA Tirre met with Administrator Jill Johnson. Facility is a three story 121 private apartment facility. There are 126 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 Tirre toured Facility with Administrator Jill Johnson. LPA toured Garden House, Garden House kitchen, Garden House resident rooms, Assisted living, Assisted Living Resident rooms, Med Tech Room, storage rooms, movie media room and Kitchen. All Resident rooms observed where within department regulations. All restrooms observed contained soap, toilet paper, and towels. Public restrooms observed to have proper Hand Washing signs. Residents were observed relaxing in the dining room eating, relaxing playing cards, reading in common areas and relaxing in bedrooms. Facility has operating smoke detectors and fire alarms which LPA observed Last fire inspection paperwork was completed in August 4, 2022 by Cinta's Fire Protection. Facility has several fire extinguishers, all which were observed as fully charged. Facility has supply of PPE. LPA observed facility has Ample 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. LPA Reviwed 8 Files of medications and resident files. Residents emergency contact information and Physicians reports are current. Facility has several designated visitation areas. Staff were observed wearing masks.

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: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022
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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