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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603371
Report Date: 10/18/2018
Date Signed: 07/23/2020 02:14:42 PM

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 OCEANSIDEFACILITY NUMBER:
374603371
ADMINISTRATOR:COOPER, ROBINFACILITY TYPE:
740
ADDRESS:3500 LAKE BLVDTELEPHONE:
(760) 414-9411
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:175CENSUS: 133DATE:
10/18/2018
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:General Manager Robin SmithTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jo Ann Legaspi conducted a case management visit to cite a deficiency observed during a complaint investigation. LPA advised General Manager (GM) Robin Smith of the visit’s purpose. GM Smith granted LPA facility entry. The investigation involved reviews of facility, hospital and medical records. The investigation also involved interviews of staff and outside sources.

Resident 1 (R1) resided in the assisted living care unit. (See LIC 811 Confidential Names). On 08/21/2018, R1 sustained a bruise while at dialysis treatment. R1 informed staff of pain to their leg thus staff administered an ice pack to the injured area. On 08/27/2018, R1’s leg wound worsened thus their responsible party brought them to the hospital where R1’s leg wound was medically examined to be infected. Staff did not perform any direct observations upon R1 from 08/22/2018 to 08/25/2018 to determine whether their leg wound had changed in condition.

Based on conducted interviews and file reviews, it has been determined that the facility failed to regularly observe R1 for any for alterations in their physical condition or provide appropriate assistance when their condition changed. This deficiency is being cited per the California Code of Regulations, (Title 22, Division 6), and described on the attached LIC 809D.



An exit interview was conducted with GM Smith. Appeal Rights (LIC 9098 01/16) along with a copy of this report was provided to GM Smith and their signature on this form confirms receipt of these rights. See Amended Report dated 7/23/20. Deficiency dismissed.
SUPERVISOR'S NAME: Tony GirolamiTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Jonathan C PinedaTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2018
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MERRILL GARDENS AT OCEANSIDE
FACILITY NUMBER: 374603371
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/18/2018
Section Cited

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Observation of the Resident – “… The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs … “ This requirement is not met as evidenced by: staff
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didn't perform any checks of R1 despite knowledge of R1’s leg wound. Residents opt out of checks by signing the facility’s refusal of checks form. Based on record reviews & conducted interviews, the Licensee failed to ensure R1 received regular checks by staff for any changed conditions, which poses as an immediate risk to residents in care.


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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2018
LIC809 (FAS) - (06/04)
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