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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603371
Report Date: 04/19/2021
Date Signed: 04/19/2021 05:13:44 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:PEREZ, MARIANOFACILITY TYPE:
740
ADDRESS:3500 LAKE BLVDTELEPHONE:
(760) 414-9411
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:175CENSUS: 97DATE:
04/19/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Teresa Jackson, Memory Care DirectorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Debbie Correia contacted Teresa Jackson, Director of Memory Care, to conduct a case management visit and virtual tour via Facetime due to COVID-19. LPA Correia identified herself and explained the purpose of the visit.

Today's visit was in response to a Resident (R1) death that occurred on April 2, 2021 and was subsequently reported to Community Care Licensing (CCL) on April 7, 2021. Caregiver Oliver Rivera accompanied LPA Correia on a virtual tour of the facility. Also, during today's visit LPA Correia interviewed staff and requested resident records maintained at the facility and obtained additional information about the death.

At the time of the visit no deficiencies were observed. An exit interview was conducted with Teresa Jackson, Director of Memory Care, and a copy of this report along with Licensee Rights (LIC 9058 01/16) was provided to Director Jackson via email. An electronic email read receipt confirms the documents were received.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
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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