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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850140
Report Date: 08/23/2023
Date Signed: 08/23/2023 05:55:22 PM

Document Has Been Signed on 08/23/2023 05:55 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: 265DATE:
08/23/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Audie Sherberg, AdministratorTIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct an annual continuation visit at 9:30 a.m. LPA met with Administrator and informed them of the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility has two large assisted living buildings. Building 1220 has 74 rooms. LPA toured 1220 building's main lobby, 3 resident rooms, dining room, theater, library, activities center, and all 4 stairwells. Building 1350 has 103 rooms. LPA toured 1350's main lobby, game room, library, wellness center, dining room, beauty shop and 4 resident rooms. The Garden House memory care has 3 buildings with 36 rooms total. LPA toured the inside and outside of The Garden House and 21 resident rooms.

Common areas: All furniture was observed to be in good condition. Carbon monoxide detectors were tested and operational at the time of the visit. LPA observed required postings throughout the common spaces. The fire extinguishers were charged and serviced on 6/14/2023.
Outdoor areas had umbrellas and other covered outdoor area equipped with furniture for resident use. Facility has a pool and spa with secure fencing. Washer and dryers were functioning and in operable condition.
Restrooms: Resident rooms had private restrooms which were clean and sanitary and in operating condition with non-skid mats/strips. All resident and public bathrooms were sufficiently stocked with soap and paper towels.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate.
Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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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