Merrill Gardens at Santa Maria.

Licensing Program Analyst (LPA) Rankin arrived at 8:49 am for the 1-year required annual visit. LPA met with Michael Easby Administrator. LPA conducted a review of the following and will return at a later date to complete the annual visit. Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 12/1/25. The facility is approved for a capacity of 330 residents. The fire clearance is granted for 330 non-ambulatory of which 20 may be bedridden. Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. Facility does submit incident reports to the department when required. LPA reviewed 10 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, and Emergency and ID forms. Disaster Preparedness: The current emergency disaster forms were reviewed. The facility last conducted a fire drill 8/21/2025. Annual fire inspection report was provided, City fire department inspected on 8/15/25, items addressed for updates were included in the report and has been completed or is scheduled Exit interview conducted and copy of report emailed for Administrator.

Record review of R1's file reveals R1 resides in assisted living but is independent of needing staff assistance. LPA interview with R1 revealed they like the facility and it's a nice place. R1 stated the Administrator is a very nice man and does not think they have ever had an issue with him. R1 stated they visited some friends last week and think they may want to move closer to the friends. R1 is not moving and no one has issued them an eviction notice. R1 has the feeling the Administrator wants them to move out, but is not sure why. During the interview R1 repeatedly asked the LPA why they were there and the LPA explained the reason each time. Staff interviews reveal no residents have been issued an eviction notice in the last two months. Staff state they have not heard of the Administrator stating he wants a resident out of the facility or threatening a resident with eviction. LPA interview with the Administrator revealed he has not issued any eviction notices to residents and has not said he wanted any residents out of the facility. The Administrator stated R1 had a change in condition recently and the facility has been working with them and their physician. Record review confirmed documentation of communication with the physician. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated , meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, report signed, and report provided to the Health Services Director.

LPA Rankin arrived at the facility, and at approximately 10:40 a.m. interviewed the Administrator. Administrator explained the facility has a non-licensed Independent Housing part of the campus and a licensed part that has a Memory Care unit, and two (2) 3-story buildings that house residents who are noted in their chart as Assisted Living and “Assisted Living No Care”. The level of care is based on assessments/evaluations conducted to establish what Adult Daily Living (ADL) care and support is needed. At approximately 10:55 a.m. LPA toured R1’s room. Evidence of bodily fluid was noted on the mattress, there was no smell observed, and the stain was in one central location of the mattress, no other concerns noted in the room. Documentation reviewed at approximately 11:15 a.m. for R1 noted on various documents such as the LIC 602A Physician’s Report, dated 04/11/2024 that the resident is independent, can manage their own medication, has no cognitive concerns, and is able to manage all ADL’s. The “Capability Evaluations” report dated 11/19/2024, in which the facility evaluates the resident for additional services needed, and the Invoice for R1 for April and May of 2025 show the rates and charges are based on “Assisted Living No Care”. There are no additional charges itemized or noted on either documents. LPA interviewed Staff 1, 2, and 3 (S1, S2, S3). All staff explained to the LPA the check in process for “Assisted Living No Care” residents. All staff stated that check-in for the “Assisted Living No Care” residents are done between 6:00 a.m. to 9:00 a.m. daily. Residents are able to check-in via an electronic button between those hours. A list is provided to caregivers by approximately 9:05 a.m. who then call or go to each resident and initial the list when a resident contact was made. Documents collected show that R1 was noted as in the dining room on 4/29/2025 and 4/30/2025. S2 initialed both days. S2 was the caregiver that responded to the initial check on 05/01/2025. S2 stated family called to say they couldn’t get a hold of R1. S2 confirmed that R1 was found in the condition noted above, with the exception of S2 did not notice eye discharge. S2 stated that R1 is a “Assisted Living No Care” resident, therefore checks are done daily during check in hours. S2 stated R1 is very independent, consistent in their schedule, and is observed daily going through their routine. Continued on 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Interview with Family 1 (F1) at 12:19 p.m. was conducted by LPA. F1 stated R1 had a massive stroke. F1 stated the facility has provided excellent care and does not have any concerns of the care provided to R1. F1 stated R1 is able to communicate since the incident and stated that the day prior to the incident, was normal for R1, that R1 had gone to dinner, returned to their room, and went to bed as normal. F1 stated R1 is independent. F1 stated another family member was scheduled to talk with R1 at 7:30 a.m. the morning of 05/01/2025 and when R1 did not call, and did not respond to calls, family member contacted the facility to provide a check on R1. That is when R1 was discovered by caregiver. F1 stated they have no concerns of R1’s care by facility. Per F1, R1 has a history of eye issues, and that R1 did have discharge when they had the stroke. At approximately 1:37 p.m. LPA began interviewing residents. All residents interviewed have no concerns about their care at the facility. Both explained they are independent and use the check in button process daily and that if they fail to check in that facility staff come to find them within the hour following 9:00 a.m. Based on interviews, observation and documentation, there is not sufficient evidence, at this time, to prove the alleged violations did occur therefore the allegations are unsubstantiated. Exit interview conducted, copy of report given.

Licensing Program Analyst (LPA) Miller arrived at 9:02 am and continued with the 1-year required annual visit initiated on 8/27/24. LPA met with Audie Sherberg Administrator and Debra Gonzales, Health Services Director. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out kiosk for visitors at entry with hand sanitizer. The facility has at least a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environment Safety: The fire extinguishers were last charged and inspected on August 21, 2024. All trash cans and wastebaskets have tight fitting covers. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors that were tested and inspected. LPA toured 10 resident rooms and observed that rooms were tidy and free of odor. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. The facility has sufficient space inside and outside for activities and visiting. Continued 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 1/1/25. The facility is approved for a capacity of 330. The fire clearance is granted for 330 non-ambulatory of which 20 may be bedridden. Facility currently has 143 Ambulatory, 51 non-Ambulatory and 3 bedridden residents. There are a total of 3 hospice residents. Staffing: The facility currently employs 111 full time staff, and 1 administrator. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator Certificate expires 9/15/24. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023 and 2024. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 10 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible, and records are kept confidential. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored, and marked appropriately. Facility has 2 large, assisted living buildings each having a septate kitchen. LPA toured kitchens at approximately 3:00 p.m. Kitchen appliances were clean and in operable condition. Cleaning solutions and equipment are stored separately from food supplies. Continued 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired and all medications were kept in their original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility last conducted a quarterly disaster drill 8/13/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in the memory care unit. The facility has delayed egress, and door alarms are working. Exit interview conducted and copy of report printed for Administrator. No deficiencies were issued.

Licensing Program Analyst (LPA) Erika Miller met with Audie Sherberg, Administrator and Debra Gonzales, Health Services Director and explained the purpose of the visit. LPA completed records review for staff and residents. LPA will need further time to complete the annual visit and return at a later date. Exit interview conducted and copy of report printed for Administrator.

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.

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.

Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. LPA met with Administrator and informed them of the reason for the visit. Records: LPA reviewed resident and staff records. LPA reviewed ten (10) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete. LPA reviewed ten (10) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete. KITCHEN: Facility has 2 large assisted living buildings each having a septate kitchen. LPA toured kitchens around 2:15pm. Kitchen appliances were clean and in operable condition. The facility has a sufficient supply of perishable and non-perishable food as well as emergency food and water. MEDICATIONS: Medications review began around 3:15 p.m. The medications are centrally stored and locked in a med cart in a medication room. Medications are labeled and checked for expiration dates. LPA advised the Administrator to ensure that all the necessary information is properly documented on the CSMAR. At 2:45 p.m., LPA interviewed three (3) care staff members. During today’s visit, the LPA obtained copies of the following: staff roster, resident roster and current liability insurance. Exit interview conducted. A copy of the report was issued.

Staff said they removed all hazardous items, unplugged their stove and placed R1 on medication management prior to R1 coming back to the facility per the new Physicians report. Staff interviewed stated that R1 and their family was very upset and asked to at least allow R1 to still have their personal cleaning supplies because the doctor said they were allowed to have access to that. LPA reviewed R1’s new Physicians report that stated on pg. 13 CA-Toxic Chemical Storage the box Yes, indicating the resident can have access to these items: “The above-named resident is able to store and use the above-named items. [Resident] is cognitively aware to know if the above-named items are swallowed or used as undirected, harm could occur.” The items listed included “Lysol and like items, bleach and like items, nail polish remover…” Regulation 87705(f) states “The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.” It is noted during this time the facility was trying to follow the doctor’s specific instruction and follow the resident’s wishes while they sought clarification about the dementia diagnosis. R1’s primary care Nurse Practitioner later clarified in writing 7/14/23 that R1 did not have a diagnosis of dementia, and should not have any restrictions as such. Based on the information obtained, the allegation is deemed Substantiated due to the facility allowing R1, who had a diagnosis of dementia, to keep cleaning supplies and disinfectants in their room. Technical Violation issued. Exit interview conducted, copy of report and appeal rights were issued. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Staff indicated that R1 has been confused and they recently issued a medication assessment to see if R1 knew their medications, what they are for, what time they are due and if there are any special instructions. Staff who were at the medication assessment stated R1 was unable to pass the assessment and may be unable to administer their own medication per instructions. Staff stated on 7/10/23 the facility received a fax from the Neurologist officially removing the dementia diagnosis as a doctor’s order and requested R1’s primary care NP to fill out a new physician’s report to reflect the correct diagnosis. LPA reviewed the note from the doctor after R1’s visit on 7/5/23. The note is written in R1’s Visit Summary, under “What to do Next” and states “It seems that sometime after your hospitalization discharge, someone said that you had dementia. It is very unclear who made this diagnosis and why. Cognitively you have continued to do well for your age. In fact we did testing today and you still perform well. As such, there is no neurological indication or reason to restrict you and your activities based on your cognition. Specially, no reason why you should not be able to cook on your own, manage taking your medications, manage your own cleaning, or travel on your own.” It was not written as a doctors order, and was just a note in the Visit Summary. LPA reviewed R1’s file which had a note from NP dated June 13, 2023 signed at 12:35pm that states “Per daughter, pt may use transportation provided by Merrill Gardens and leave facility and (R1) will have a caregiver who can also take (R1) out.” LPA observed another note from NP dated June 13, 2023 signed at 1:33pm that states “Pt may only leave facility if (R1) has someone to accompany (R1). Disregard prior order.” On 7/14/23 NP signed another note at 9:33am stating “Please allow (R1) to come and go as (R1) pleases. Please disregard previous orders regarding leaving building.” On 7/13/23 R1’s NP filled out a new physician’s report and the facility gave R1 access to their stove again and let them leave the facility unassisted. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. On the allegation: Facility violated resident’s personal rights. It was alleged that the facility violated R1’s personal rights when offering to give R1 a shower. Reporting party stated that R1 told them they were “upset” and “humiliated” when staff came downstairs and “forced” R1 to take a shower. LPA interviewed staff who stated that R1 was put on showers per doctors’ orders and wasn’t in their room when staff went to offer them a shower. After two days of not being in their room during shower time, staff stated they found R1 alone in the library and asked them to come upstairs to take a shower. R1 didn’t want to take a shower and refused. Another staff came to assist and stated that R1 said they don’t need help showering but staff reminded them they were asked by the doctor to assist with showers and said, “you will feel better after your shower.” Resident went upstairs to shower. Continued on 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Staff interviewed stated the resident didn’t seem upset or humiliated and there were no other residents around when they asked. LPA interviewed R1 who stated they never were asked to take a shower and no staff ever came in their room to help with a shower. LPA stated that a few weeks ago it was reported you were upset because a staff came and embarrassed you in the library and forced you to take a shower. R1 asked who said that and stated that never happened. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of report issued.