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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202572
Report Date: 10/12/2021
Date Signed: 10/13/2021 08:44:26 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MERRILL GARDENS AT CAMPBELLFACILITY NUMBER:
435202572
ADMINISTRATOR:WELCH, JOYCEFACILITY TYPE:
740
ADDRESS:2115 S WINCHESTER BLVDTELEPHONE:
(408) 370-6454
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:166CENSUS: 155DATE:
10/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Joyce WelchTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an annual inspection today and met with General Manager Joyce Welch (GM). At 10:00 AM, LPA entered the facility through the main entrance point and was screened by staff. At 10:05 AM, a tour of the facility's assisted living building B was conducted with staff. COVID-19 postings were observed in the hallways and some, but not all common areas. Staff were observed wearing face coverings. Bistro ceiling noted to have ceiling tiles missing, GM indicated that a resident accidentally flooded their bathroom, and it caused leaking from the ceiling on 10/11/2021. Facility is currently ensuring that there is no water damage and that the area has fully dried. Facility already have ceiling tiles ready to replace the damaged ones.

During tour of building D, LPA noted that public bathrooms did not have handwashing signs, or lidded trash cans and one bathroom was out of paper towels. Paper towels were restocked moments later. Facility temperature noted to be between 68*F and 79*F. Facility water temperature measured to be between 115.5*F and 116.0*F. Fire extinguishers noted to be last inspected in March of 2021.

Hand sanitizers, soap, and paper supplies were observed available. At least 30 days' supply of personal protective equipment (PPE) were available in the premises. Per Administrator, the facility is currently accepting visitors inside the facility, including residents' bedrooms. The facility has reached a 100% COVID-19 vaccination rate for staff and 100% save 1 for residents. The facility's COVID-19 mitigation plan has been reviewed and is still in place.

No deficiencies were cited. Advisory notes issued. Exit interview conducted with GM and a copy of this report was provided during visit.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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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