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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850140
Report Date: 10/04/2023
Date Signed: 10/04/2023 02:32:44 PM

Document Has Been Signed on 10/04/2023 02:32 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: 224DATE:
10/04/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Brenda Steed, Business Office ManagerTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct an annual continuation visit at 11:00 a.m. LPA met with Business Office Manager and informed them of the reason for the visit.

LPA reviewed facility staff training, criminal record clearance, and completed the remaining CARE Tool questions.

At 1:45 pm -2:30 pm LPA interviewed 5 residents.

Exit interview completed, copy of report issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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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