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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603371
Report Date: 09/15/2021
Date Signed: 09/17/2021 10:41:37 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: 115DATE:
09/15/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Administrator, Mariano PerezTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA), Kristina Ryan, conducted a Plan of Correction visit for deficiency cited on August 25, 2021. LPA met with and was granted entry in to the building by Administrator, Mariano Perez. LPA was allowed entry into the facility after identifying herself and stating the purpose of the visit.

Citation: 87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement was not met as evidenced by: Based on observations, the memory care units in Garden House 2 and 3, which house more than 16 residents did not have a signal system in each resident unit. This posed a potential safety risk to all memory care residents.

Plan of Correction: Administrator provided work order receipts and installation information to LPA on September 2, 2021. Administrator requested a Plan of Correction extension until September 16, 2021 for installation of the signal system.

LPA reviewed the work order and tested a sampling of the signal system pull cords in both memory care units. Deficiency cleared.

An exit interview was conducted, and a copy of this report, Licensee's Rights (9058 01/16), Letter of Deficiency Cleared, were emailed to the Administrator. An electronic receipt confirms receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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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