306005275-11-22-2022-22-AS-LADS-CM5T7W-20221215132922

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005275
Report Date: 11/22/2022
Date Signed: 11/22/2022 04:14:16 PM

Unfounded

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
08/11/2021 and conducted by Evaluator Jenifer Tirre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210811084236

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: 128	DATE:	11/22/2022
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Administrator, Jill Johnson		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Facility vehicle is not properly maintained

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to deliver findings on complaint investigation. LPA met with Administrator Jill Johnson.
During the course of investigation, LPA conducted interviews and gathered pertinent documentation. Based off the information provided from observation and interviews regarding the allegation Facility vehicle is not properly maintained, the investigation revealed the following; facility has two transportation vehicles used for transporting residents a Van and a town car. LPA observed facility vehicles invoices for inspection dated 6/7/21. In June of 2021, facility van had Catalytic Converter stolen and facility provided proof of invoice of new Converter installed dated 6/9/21. Facility provided proof of insurance and DMV registration which is current. Facility Vehicle Inspection logs dated from 4/18/21 to 7/29/21 are noted as completed and satisfactory. Investigation also revealed that Facility vehicles get a monthly car wash, an oil change every 3,000 miles, and a CHP inspection every three months. As of today's visit a recent Smog Check inspection pass report dated 3/9/22 and a recent Labor Safety Inspection report dated 11/12/22 was observed.
CONTINUED ON 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

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-20210811084236

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: 11/22/2022

NARRATIVE

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This agency has investigated the allegation Facility vehicle is not properly maintained. Based off observations and documentation the department has found that the complaint is deemed UNFOUNDED meaning that the allegation was false, could not have happened and / or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Administrator and a copy of report was left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

LIC9099 (FAS) - (06/04)

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