425850140-8-24-2022-29-AS-JOLN-CHLR9F-20220824124928

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850140
Report Date: 08/24/2022
Date Signed: 08/24/2022 12:50:10 PM

Document Has Been Signed on 08/24/2022 12:50 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 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:	08/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Audie Sherberg, Administrator		TIME COMPLETED:	01:00 PM

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Licensing Program Analyst's (LPA) Olson conducted an on-site 1 year infection control annual visit to the facility above on 08/24/2022 at 9:45 AM. LPA met with Administrator Audie Sherberg and explained the purpose of the visit.

LPA took a physical plant tour of the facility with Administrator. The facility has submitted a mitigation plan to the department, and it has been approved. The facility has 5 separate buildings. each building has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening for all staff and visitors wanting to come into the facility. All documentation is kept in a file. The entry station has hand sanitizer along with a thermometer. The facility has multiple areas spaced to accommodate as much space as possible for social distancing. All equipment and PPE supplies are kept in the storage closets. Medications are kept in a locked medication room. The staff screen residents for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. Signs are posted on the front door, entry area regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents.

Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Director of Health Services is in charge of infection control and provides training and education to staff, residents and visitors.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MERRILL GARDENS AT SANTA MARIA	FACILITY NUMBER: 425850140
	VISIT DATE: 08/24/2022

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If any suspected or confirmed cases of Covid-19 are found in the facility a staff will use full PPE with N95 masks, face shield, gloves, and gowns when dealing with any residents. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. PPE supplies will be located right outside isolation rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room. Facility has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in secured offices or med rooms. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Administrator Certificates are valid. Fire extinguishers were charged and inspected annually. The facility has hardwired smoke and carbon monoxide detectors thorough the facility.

Exit interview completed, no deficiencies were observed, a copy of report is emailed to Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

LIC809 (FAS) - (06/04)

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