306005275-11-1-2024-22-AS-JTIE-DALW2N-20241101165437

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005275
Report Date: 11/01/2024
Date Signed: 11/01/2024 04:55:03 PM

Document Has Been Signed on 11/01/2024 04:55 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	MERRILL GARDENS AT HUNTINGTON BEACH		FACILITY NUMBER:	306005275
ADMINISTRATOR/ DIRECTOR:	JOHNSON, JILL		FACILITY TYPE:	740
ADDRESS:	17200 GOLDENWEST ST		TELEPHONE:	(714) 842-6569
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY: 150	TOTAL ENROLLED CHILDREN: 0	CENSUS: 112	DATE:	11/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:05 AM
MET WITH:	Executive Director Jill Johnson		TIME VISIT/ INSPECTION COMPLETED:	05:10 PM

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On 11/1/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Executive Director (ED) Jill Johnson was present to assist with the facility inspection on today's date.

The facility is licensed for one hundred fifty (150) non-ambulatory residents with approved hospice waiver for fifteen (15) residents and fifteen (15) Bedridden. Currently, there are three (3) Hospice residents present during today’s visit.

This is a three story with attached Memory Care facility . The facility is 121 private apartment facility. There are 112 residents present during facility visit.

At around 10:16AM, LPA conducted a tour of the physical plant accompanied by Executive Director, and the following was observed: There were no bodies of water on the premises. All resident rooms observed met department regulations. LPA inspected 15 resident rooms. Resident beds and bedding supplies were in operational condition, lighting was provided, and storage for the residents personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. LPA checked water temperature in 9 resident Bathrooms and found water temperature measured between 106.5 to 115.3 degrees F. A comfortable temperature of 78 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. LPA observed emergency food and water supply. Facility has 5 drums of emergency water. Facility has Easy meal kits that feed 25 individuals per kit. LPA observed 25 boxes of meal kits. LPA observed eight fire extinguishers all mounted and fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed of the records reviewed all are in compliance.
CONTINUED ON 809C

Lourdes Montoya	TELEPHONE: (714) 703-2870
Jenifer Tirre	TELEPHONE: (714) 401-6844
	DATE: 11/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MERRILL GARDENS AT HUNTINGTON BEACH	FACILITY NUMBER: 306005275
	VISIT DATE: 11/01/2024

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

During visit LPA observed residents relaxing in dining room or common areas eating meals, playing
card games and reading newspapers. LPA observed several residents relaxing inside private apartments watching TV and or knitting.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 10/11/24. The facility had operational smoke and carbon monoxide in bedrooms and common areas. LPA observed documentation from Cosco Fire Protection and Direct Supply Tels. confirming 229 smoke detectors passed on inspection date 10/15/2024. The facility has current liability insurance on file effective 01/01/2024 - 01/01/2025. The facility is current on Community Care Licensing annual dues.

A review of five residents (R1-R5) service files and four staff (S1-S4) personnel files revealed to be complete. Facility has a secured location for resident medication and files.

No deficiencies during this inspection visit.

An exit interview was conducted with Executive Director, and a copy of the report was provided.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024

LIC809 (FAS) - (06/04)

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