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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850140
Report Date: 08/26/2021
Date Signed: 08/26/2021 06:39:57 PM

Document Has Been Signed on 08/26/2021 06:39 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: 207DATE:
08/26/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:AUDIE SHERBERGTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Arien Diaz conducted a Pre-licensing visit at the facility. There are 3 one-story memory care buildings and 2 three-story assisted living buildings which will be licensed as a Residential Care for The Elderly. LPA met with Administrator, Audie Sherberg and Staff Chris Ragan.

LPA toured the memory care buildings and observed that the facility consists of 36 bedrooms and bathrooms, 3 storage closets, and 3 kitchens. LPA observed 3 resident bathrooms, and hot water temperature read at 113 degrees in bathrooms. There are grab bars for each toilet. In the kitchen, hot water temperature read at 113 degrees. The facility maintains a comfortable temperature of 73 degrees. LPA observed working smoke detectors and carbon monoxide detectors. The facility has hallway lights. LPA observed a complete First Aid Kit. LPA observed the complaint poster and personal rights posted. LPA observed an appropriate signage for covid-19. LPA observed fully charged fire extinguishers. LPA observed sharp objects, soaps and toxins in locked cabinets in the kitchen/storage. Resident medication and resident records are kept in a locked filing cabinet in a locked medication room.

LPA toured the assisted living buildings and observed that the facility consists of 176 bedrooms and bathrooms, 6 storage closets, and 2 kitchens. LPA observed 3 resident bathrooms, and hot water temperature read at 115 degrees in bathrooms. There are grab bars for each toilet. In the kitchens, hot water temperature read at 114 degrees. The facility maintains a comfortable temperature of 72 degrees. LPA observed working smoke detectors and carbon monoxide detectors. The facility did have hallway lights. LPA observed a complete First Aid Kit. LPA observed the complaint poster and personal rights posted. LPA observed an appropriate signage for covid-19. LPA observed 16 fully charged fire extinguishers. LPA observed sharp objects, soaps and toxins in locked cabinets in kitchen/storage room. The facility has adequate emergency supplies including nonperishable foods..

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MARIA
FACILITY NUMBER: 425850140
VISIT DATE: 08/26/2021
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The facility has 2 backup generators in the back shed. The facility has 2 containers of 260 gallons of emergency water in the back shed. The facility had an adequate supply of PPE. LPA toured the exterior of the facility and observed screens on all the windows and the facility is clean and in good repair. Resident medication and resident records are kept in a locked filing cabinet in a locked medication room near the Administrator office area.

The following items are needed prior to Licensure: Provide dresser and night stand in 1st floor resident room or signed documentation requesting no furniture needed by resident. Provide rubber bathroom mats for residents without rubber mats in both memory care and assisted living.

Exit interview conducted, copy of report provided, emailed for signature.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC809 (FAS) - (06/04)
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