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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604405
Report Date: 02/01/2024
Date Signed: 02/01/2024 12:35:22 PM


Document Has Been Signed on 02/01/2024 12:35 PM - It Cannot Be Edited

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 HILLFACILITY NUMBER:
374604405
ADMINISTRATOR:HANSEN, LORIFACILITY TYPE:
740
ADDRESS:2567 2ND AVENUETELEPHONE:
(619) 209-5216
CITY:SAN DIEGOSTATE: CAZIP CODE:
92103
CAPACITY:100CENSUS: 89DATE:
02/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:General Manager Lori HansenTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with General Manager Lori Hansen. LPA also met with Resident Service Director Kelly Biondo during the visit.

Today's visit was in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 01/26/2024. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 01/20/2024.

During today’s visit, LPA performed a brief facility tour and welfare check on remaining residents, finding no safety concerns. LPA also collected copies of and reviewed pertinent records and interviewed relevant staff.

Per review of care records: R1 moved into the facility in May 2023. At that time, Licensee had obtained a recent Medical Assessment (i.e., an LIC602 Physician’s Report dated 04/18/2023) on R1. However, the LIC602 did not indicate whether a test for tuberculosis (TB) was performed on R1. LPA asked multiple managers if there was some other written record of R1 having a negative TB test result from the time of their move-in, but none could be produced during today’s visit.

Staff interviews confirmed that R1 did not exhibit TB symptoms during their stay at the facility. Nothing in R1’s internal or external care records, which LPA reviewed today, suggested that R1 was ever infected with TB during their stay at the facility. R1 had a subsequent chest X-ray on 01/02/2024, which did not show evidence of TB. Per R1’s official Death Certificate, their death was unrelated to TB.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
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 BANKERS HILL
FACILITY NUMBER: 374604405
VISIT DATE: 02/01/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPA also issued one (1) Technical Violation (TV) regarding reporting requirements (see the LIC 9102-TV page).

An exit interview was conducted with Hansen, to whom a copy of this report, the LIC809-D, the LIC9102-TV, and the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/01/2024 12:35 PM - It Cannot Be Edited

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 BANKERS HILL
FACILITY NUMBER: 374604405

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/02/2024
Section Cited
CCR
87458(b)(1)

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87458 Medical Assessment: “(b) The medical assessment shall include…: (1) A physical examination of the resident…and results of an examination for communicable tuberculosis…” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, R1 had already passed away. Licensee agreed to implement a process whereby the facility representative who signs the admissions agreement with a residents’ responsible person also personally double-checks that said resident’s LIC602 Physician’s Report is signed and complete, as they are scheduling the contract signing meeting. Licensee also agreed to retrain all facility staff who are directly involved with the admissions/move-in process on Regulation 87458, titled “Medical Assessment,” and to submit the training sign-in sheet to LPA, by the POC due date.
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Based on records review and manager interview: Licensee did not ensure that the medical assessment for 1 of 89 residents (R1) included the results of an examination for communicable tuberculosis, which posed a potential health and safety risk to persons 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
LIC809 (FAS) - (06/04)
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