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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604405
Report Date: 04/12/2024
Date Signed: 04/12/2024 05:03:00 PM


Document Has Been Signed on 04/12/2024 05:03 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
SAN DIEGO RO, 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:
04/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lori Hansen Senior General ManagerTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA), Amy Domingo, conducted an unannounced Case Management visit. The LPA introduced himself and disclosed the purpose to Marketing Director, Dayna Farris and Med Tech, Jessica Ortiz and later with Lori Hansen Senior General Manager.

Today's visit was in response to an Incident Report submitted to the Department, for Resident 1 (R1). [See LIC 811 Confidential Names List for a description of R1]. R1 sustained a fall on 04/02/2024, was transported to the hospital and passed away on 04/02/2024. The LPA conducted a tour of the facility and secured pertinent records. No health and safety concerns were identified and no deficiencies were cited during today's visit.

An exit interview was conducted with Senior General Manager Lori Hansen, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
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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