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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603371
Report Date: 06/03/2021
Date Signed: 06/04/2021 08:06:08 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 OCEANSIDEFACILITY NUMBER:
374603371
ADMINISTRATOR:PEREZ, MARIANOFACILITY TYPE:
740
ADDRESS:3500 LAKE BLVDTELEPHONE:
(760) 414-9411
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:175CENSUS: 107DATE:
06/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Administrator, Mariano PerezTIME COMPLETED:
12:10 PM
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Licensing Program Analysts (LPA's), Kristina Ryan, and Alexandre Vo conducted an unannounced case management visit, LPA's identified themselves and stated the purpose of the visit to Administrator, Mariano Perez.

On June 1, 2021, the facility self-reported an incident regarding Resident 1 (R1) to Community Care Licensing.

On today’s date, LPA's requested copies of facility records, toured the facility, and interviewed staff. No deficiencies were cited at this time. Future visits may be necessary.

An exit interview was conducted with Administrator, Mariano Perez to whom a copy of this report, LIC 811 Confidential Names list, and the Licensee/Appeal Rights (9058 01/16) were provided via e-mail. An electronic read receipt verifies receipt of these documents.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
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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