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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202572
Report Date: 10/13/2022
Date Signed: 10/13/2022 03:27:07 PM


Document Has Been Signed on 10/13/2022 03:27 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
CENTRAL COAST CR/RES, 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: 154DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Sarum TalivaaTIME COMPLETED:
03:26 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an annual inspection today and met with Residential Services Manager Sarum Talivaa (RSM). At 01:20 PM, LPA entered the facility through the main entrance point and was screened by staff. COVID-19 postings were observed in the hallways and common areas. Staff were observed wearing face coverings. Ceiling noted to be damaged in previous facility inspection noted to have been repaired.

All bathrooms noted to have handwashing signs, lidded trash cans soap and paper towels. Facility temperature noted to be between 68*F and 77*F. Facility water temperature measured to be between 110.2*F and 114.7*F. Fire extinguishers noted to be last inspected in March of 2022. No prohibited items noted in inspected resident rooms. All emergency exits noted to be clear of obstruction. Delayed egress doors tested and noted to be functioning properly.

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% for residents. The facility's COVID-19 infectious control plan has been reviewed and is still in place.

No deficiencies were cited. No 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: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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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