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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850140
Report Date: 11/13/2023
Date Signed: 11/13/2023 03:21:01 PM

Document Has Been Signed on 11/13/2023 03:21 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MERRILL GARDENS AT SANTA MARIAFACILITY NUMBER:
425850140
ADMINISTRATOR:SHERBERG, AUDIEFACILITY TYPE:
740
ADDRESS:1220 SUEY ROADTELEPHONE:
(206) 676-5300
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 330CENSUS: 260DATE:
11/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Audie Sherberg, AdministratorTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted a Case Management - Incident visit to issue deficiencies on an elopement the facility self-reported. LPA and met with Audie Sherberg, Administrator and explained the purpose of the visit.

CCL received an incident report on 10/30/23 stating that on 10/28/23 Staff discovered Resident 1 (R1) was missing from Memory Care around 6:55 pm and could not locate them. Staff called 911 and conducted a search throughout the community, outside the community and surrounding areas. At around 7:21 pm Santa Maria Police Department called to say R1 was found and was taken to the hospital for evaluation. Resident was found on the corner of Rose and Suey Rd. and the paramedics were called because R1 fell. A CT was done and R1 was admitted for a Brain Bleed.

LPA received a call/voicemail from the Garden House Director on Sunday 10/29/23 at 9:02 am explaining what happened. Administrator called LPA Monday 10/30/23 and stated R1 was on blood thinners which lead to the brain bleed, was doing well and no longer in the ICU and will be coming back to the facility soon. Administrator stated they are not sure how R1 got out of the double locked doors of the home and the locked fence.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

An immediate $500 civil penalty was assessed due to the resident being injured during their elopement.

An exit interview was conducted, a copy of the report, Civil Penalty, and appeal rights were issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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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Document Has Been Signed on 11/13/2023 03:21 PM - It Cannot Be Edited


Created By: Jeannette Olson On 11/13/2023 at 09:05 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MERRILL GARDENS AT SANTA MARIA
FACILITY NUMBER: 425850140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2023
Section Cited
CCR
87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ,,,(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not
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Garden House Director conducted training to all Garden House staff and provided documentation to LPA. POC was cleared durring the visit
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met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when staff did not ensure R1’s safety when they wandered away from the facility which resulted in a fall and brain bleed, which posed an immediate health and safety risk to
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resident 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:Kelly Burley
LICENSING EVALUATOR NAME:Jeannette Olson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
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