425850140-8-22-2023-29-AS-KBUY-CV4K4K-20230827073427

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850140
Report Date: 08/22/2023
Date Signed: 08/22/2023 06:19:34 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2023 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20230706143740

FACILITY NAME:	MERRILL GARDENS AT SANTA MARIA		FACILITY NUMBER:	425850140
ADMINISTRATOR:	SHERBERG, AUDIE		FACILITY TYPE:	740
ADDRESS:	1220 SUEY ROAD		TELEPHONE:	(206) 676-5300
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	330	CENSUS: 265	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Audie Sherberg, Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility didn’t meet the residents needs after a new diagnosis of dementia

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA interviewed staff, Administrator and Resident 1 (R1) on 7/11/23 and R1’s Nurse Practitioner on 7/14/23. LPA met with Administrator and explained the purpose of the visit.

On the allegation: Facility didn’t meet the residents needs after a new diagnosis of dementia. It was alleged that the facility “pick and choose” which dementia regulations to follow and didn’t allow R1 to leave the facility unassisted, unplugged their stove, put R1 on medication management, didn’t allow the resident to leave independently and installed a door alarm but allowed R1 to keep their personal cleaning supplies including ajax and bleach in their room. Interviews with staff revealed that R1 was diagnosed with dementia on 6/1/23 at a Skilled Nursing Facility.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 29-AS-20230706143740

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/22/2023

NARRATIVE

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Staff said they removed all hazardous items, unplugged their stove and placed R1 on medication management prior to R1 coming back to the facility per the new Physicians report. Staff interviewed stated that R1 and their family was very upset and asked to at least allow R1 to still have their personal cleaning supplies because the doctor said they were allowed to have access to that. LPA reviewed R1’s new Physicians report that stated on pg. 13 CA-Toxic Chemical Storage the box Yes, indicating the resident can have access to these items: “The above-named resident is able to store and use the above-named items. [Resident] is cognitively aware to know if the above-named items are swallowed or used as undirected, harm could occur.” The items listed included “Lysol and like items, bleach and like items, nail polish remover…” Regulation 87705(f) states “The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.” It is noted during this time the facility was trying to follow the doctor’s specific instruction and follow the resident’s wishes while they sought clarification about the dementia diagnosis. R1’s primary care Nurse Practitioner later clarified in writing 7/14/23 that R1 did not have a diagnosis of dementia, and should not have any restrictions as such. Based on the information obtained, the allegation is deemed Substantiated due to the facility allowing R1, who had a diagnosis of dementia, to keep cleaning supplies and disinfectants in their room. Technical Violation issued.

Exit interview conducted, copy of report and appeal rights were issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2023 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20230706143740

FACILITY NAME:	MERRILL GARDENS AT SANTA MARIA		FACILITY NUMBER:	425850140
ADMINISTRATOR:	SHERBERG, AUDIE		FACILITY TYPE:	740
ADDRESS:	1220 SUEY ROAD		TELEPHONE:	(206) 676-5300
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	330	CENSUS: 265	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Audie Sherberg, Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility did not follow doctor’s note
Facility violated resident’s personal rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA interviewed staff, Administrator and Resident 1 (R1) on 7/11/23 and R1’s Nurse Practitioner (NP) on 7/14/23. LPA met with Administrator and explained the purpose of the visit.

On the allegation: Facility did not follow doctor’s note. It was alleged that Resident 1 (R1) saw a Neurologist on 07/05/23 who stated that R1 does not have dementia and could cook, manage their own medication, and leave the facility unassisted but the facility did not follow the note and still restricted R1 from these activities. Interviews with staff and Administrator indicated that they received the note but needed a new Physician’s report indicating that R1 does not have dementia. Administrator also indicated they wanted documentation from the physician indicating that R1 does not have dementia and was incorrectly diagnosed with it, for their own records and due diligence.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20230706143740

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/22/2023

NARRATIVE

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Staff indicated that R1 has been confused and they recently issued a medication assessment to see if R1 knew their medications, what they are for, what time they are due and if there are any special instructions. Staff who were at the medication assessment stated R1 was unable to pass the assessment and may be unable to administer their own medication per instructions. Staff stated on 7/10/23 the facility received a fax from the Neurologist officially removing the dementia diagnosis as a doctor’s order and requested R1’s primary care NP to fill out a new physician’s report to reflect the correct diagnosis.

LPA reviewed the note from the doctor after R1’s visit on 7/5/23. The note is written in R1’s Visit Summary, under “What to do Next” and states “It seems that sometime after your hospitalization discharge, someone said that you had dementia. It is very unclear who made this diagnosis and why. Cognitively you have continued to do well for your age. In fact we did testing today and you still perform well. As such, there is no neurological indication or reason to restrict you and your activities based on your cognition. Specially, no reason why you should not be able to cook on your own, manage taking your medications, manage your own cleaning, or travel on your own.” It was not written as a doctors order, and was just a note in the Visit Summary. LPA reviewed R1’s file which had a note from NP dated June 13, 2023 signed at 12:35pm that states “Per daughter, pt may use transportation provided by Merrill Gardens and leave facility and (R1) will have a caregiver who can also take (R1) out.” LPA observed another note from NP dated June 13, 2023 signed at 1:33pm that states “Pt may only leave facility if (R1) has someone to accompany (R1). Disregard prior order.” On 7/14/23 NP signed another note at 9:33am stating “Please allow (R1) to come and go as (R1) pleases. Please disregard previous orders regarding leaving building.” On 7/13/23 R1’s NP filled out a new physician’s report and the facility gave R1 access to their stove again and let them leave the facility unassisted. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

On the allegation: Facility violated resident’s personal rights. It was alleged that the facility violated R1’s personal rights when offering to give R1 a shower. Reporting party stated that R1 told them they were “upset” and “humiliated” when staff came downstairs and “forced” R1 to take a shower. LPA interviewed staff who stated that R1 was put on showers per doctors’ orders and wasn’t in their room when staff went to offer them a shower. After two days of not being in their room during shower time, staff stated they found R1 alone in the library and asked them to come upstairs to take a shower. R1 didn’t want to take a shower and refused. Another staff came to assist and stated that R1 said they don’t need help showering but staff reminded them they were asked by the doctor to assist with showers and said, “you will feel better after your shower.” Resident went upstairs to shower. Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20230706143740

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/22/2023

NARRATIVE

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Staff interviewed stated the resident didn’t seem upset or humiliated and there were no other residents around when they asked. LPA interviewed R1 who stated they never were asked to take a shower and no staff ever came in their room to help with a shower. LPA stated that a few weeks ago it was reported you were upset because a staff came and embarrassed you in the library and forced you to take a shower. R1 asked who said that and stated that never happened. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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