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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850140
Report Date: 05/12/2022
Date Signed: 05/12/2022 11:32:02 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/21/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220421143113
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: 245DATE:
05/12/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Audie Sherberg, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility did not provide a safe environment for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to the facility to issue final findings. LPA met with Audie Sherberg, Administrator, and explained the purpose of the visit.

The facility has been renovating one of the memory care buildings, including painting and new flooring that commenced on 4/18/22. On 4/25/22 at around 4:00pm, LPA Olson toured the facility and observed the facility smelled like paint fumes. LTCO Viviana Padova arrived at the facility around 4:30pm and stated that “it smelled like fumes, like gas.”
On 4/25/22, LPA interviewed Administrator and staff regarding the allegation. Administrator stated the facility created a plan to paint and moved residents for the day while the paining occurred. Administrator stated resident’s responsible parties were informed of the plan. Staff 1 stated that the current smell and fumes had improved from the last week, when the walls were painted with a paint sprayer.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20220421143113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/12/2022
NARRATIVE
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 A credible witness (W1) stated on 4/20/2022 at 3:30am, W1 observed Resident 1 (R1) in respiratory distress and stated that even with an N95 mask on, they could smell the strong paint fumes. Administrator and staff stated they open windows and doors for ventilation during the day, but do not leave any windows open overnight or run fans. On 04/27/2022, Administrator submitted a plan to CCL of how they will attempt to mitigate the paint fumes going forward with the renovations. Based on the information obtained, this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Licensee/Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220421143113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/12/2022
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities
...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator submitted a plan to CCL on 04/27/2022 stating how they will attempt to mitigate the paint fumes going forward with the renovations. The Plan of Correction was cleared during the visit.
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Based on LPA observation and interviews, the licensee did not ensure a safe environment for residents while renovating, which poses a potential health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3