374603274-5-26-2021-08-AS-ETOS-C3DJJM-20210526070546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603274
Report Date: 05/25/2021
Date Signed: 05/26/2021 07:05:50 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	MERRILL GARDENS AT BANKERS HILL		FACILITY NUMBER:	374603274
ADMINISTRATOR:	LORI HANSEN		FACILITY TYPE:	740
ADDRESS:	2567 2ND AVE		TELEPHONE:	(619) 209-5216
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92103
CAPACITY:	100	CENSUS: 86	DATE:	05/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Executive Director, Lori Hansen		TIME COMPLETED:	12:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Eva Torres conducted an unannounced infection control inspection. LPA met with Executive Director, Lori Hansen. The purpose of today's visit is to inspect and ensure that the facility is following the California Code of Regulations, Title 22, Division 6. The facility is licensed for hundred (100) non-ambulatory elderly residents, in which five (5) residents may be bedridden.

Tour included:

Infection Control: LPA reviewed and discussed the Mitigation Plan with the Executive Director. LPA also provided consultation while reviewing the facility's training records, staffing plan, and screening protocols, including but not limited to inspecting their disinfectant supply and the use of personal protective equipment (PPE). Mrs. Hansen was advised to remain updated on the changes and directions set forth by the department, so that their COVID’s policy reflects the current information on COVID’s guidelines.

Physical Plant: front entrance, interior, and exterior surroundings were observed to be clean with no pathway obstruction. LPA inspected the fire extinguishers and found them to be in compliance. The facility does not have firearms and or ammunition on the grounds.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents.

Records: The staff assisting the LPA with the inspection has a criminal record clearance in file and is associated to the facility. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expires on 06/09/22. The last fire was conducted on 04/14/21.

Based on today’s inspection, there were no deficiencies observed per Title 22 Regulation. LPA conducted an exit interview with the Executive Director. A copy of this report and the Licensee Rights (LIC 9058 01/16) was provided to the Executive Director, and their signature on this form confirms receipt of documents

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica Torres	TELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

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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