Merrill Gardens at Bankers Hill

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with General Manger Jill Johnson. According to the facility’s license, the facility has a maximum capacity of one hundred (100) residents eighty five (85) of whom may be non-ambulatory and fifteen (15) may be bedridden. This facility does not feature a secured perimeter or delayed egress doors. LPA's, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA's interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with General Manager Jill Johnson, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 21, 2026

Allegation investigated: Staff did not provide reasonable privacy to resident in care

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to General Manager Jill Johnson. During today’s visit, LPA observed residents in care, interviewed staff and obtained copies of facility records. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. On June 15, 2025 , the Department received a complaint alleging that staff did not provide reasonable privacy to the resident in care, specifically Resident #1 (R1) Email correspondence dated April 25, 2025 from R1's Responsible person to Senior General Manager(ED) Hansen instructed ED Hansen not to contact the hospital and stated that R1 reposnsible person was the designated representative for updates. (Continued on LIC9099) Substantiated LIC9099-C Continuation Page (Report 1) Department review of facility records document Release of Client/Resident Medical Information was signed. However, the document includes language that the person who authorized this release may revoke this authorization at any time. Department records review reveal and email correspondence dated April 25, 2025 from R1's responsible person to ED Hansen instructing ED Hansen not to contact the hospital and stated that R1's responsible person was the designated representative for updates. ED responded in writing:“As long as (R1) is my resident, I am required and mandated by the Dept of Social Services to speak with the hospital to have updates and make progress notes on (R1's) chart at my community. I / or someone designated on our community’s behalf, will be calling every single day [R1} in the hospital and / or in a rehab to get updates and notating." The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. An exit interview was conducted with General Manager Jill Johnson, whose signature below confirms receipt of a copy of this report, LIC811, and the Licensee Appeal Rights (LIC9058 03/22). (continued from LIC9099) page Department Interviews with staff and review of facility records revealed that an Incident Report dated May 21, 2025 documented a fall, emergency services was called, and notifications were made to the physician and responsible party. Another Incident Report dated July 11, 2025 documented ER transport for hip pain; however, no fall was referenced. Review of the Service Plan dated May 9, 2025 showed toileting assistance was included, and care logs reviewed indicated services were provided as scheduled. Pharmacy fax dated May 10, 2025 and the MAR were reviewed, and no evidence of medication mismanagement was found. Invoices and care logs reviewed confirmed that Level 8 services billed during June and July 2025 were delivered by facility staff. Department Interviews with staff and outside sources did not reveal any concerns regarding toileting delays, medication errors, or unreported falls beyond what was documented. Documentation reviewed supports that facility staff performed required care tasks and provided billed services. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of evidence has not been met; therefore, these allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with General Manager Jill Johnson, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Feb 13, 2026 · control 08-AS-20250715131154

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Mar 13, 2026

87468.2(a)(2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as evidenced by: Based on interviews and records review, Licensee did not ensure resident privacy rights were maintained. This posed a potential personal rights risk to 1 of 84 residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2026

Plan of correction: The facility shall provide staff training to ensure resident privacy rights are maintained, including honoring the designated representative decision to revoke the authorization at any times. Proof of policy and training shall be submitted to CCL by the POC date.

Allegation investigated: Staff did not address resident's change in condition

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself, was greeted by facility staff, and explained the purpose of the visit to General Manager Jill Johnson During today’s visit, LPA observed residents in care and obtained copies of facility records and interviewed staff..The Department’s investigation consisted of interviews with staff and outside sources, records review, and observations. On January 22, 2025, the Department received a complaint alleging that staff did not address a resident’s change in condition. More specifically, it was alleged that Executive Director (ED) Lori Hansen interfered with staff documentation related to Resident #1(R1) change of condition. It was reported that the R1dementia is progressing and requires a higher level of care. (Continued on LIC9099-C). Unsubstantiated (continued from LIC 9099) Review R1's Physician’s Report dated November 11, 2024, revealed diagnoses of Mild Cognitive Impairment (MCI) and Major Depressive Disorder (MDD), along with a history of traumatic subdural hemorrhage. The Physician’s Report does not include a dementia diagnosis. Review of R1's Care Service Plan assessed on June 1, 2025, and effective June 22, 2025, revealed the resident is non-ambulatory, requiring two-person assist for transfers, frequent hands-on assistance with toileting and dressing, total assistance with showers, drainage bag management four times daily, and medication management. The plan also notes high fall risk and behavioral refusals of care. Interviews with staff revealed they did not confirm being instructed by S1 to omit or delay documentation related to changes of condition. However, an interview with an outside source revealed S1 accompanied R1 and two outside sources to R1's physician appointment. The outside source reported that during this visit, S1 had a private discussion with the attending physician outside the room. The outside source could not confirm the content of that discussion. The Department has investigated the above-mentioned allegation and based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with General Manager Jill Johnson, whose signature below confirms receipt of a copy of this report, LIC811 Confidential Names list, and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Feb 5, 2026 · control 08-AS-20250122094452

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA's) Amy Rodgers and Angelica Boyles conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA's were welcomed by, identified themselves to, and discussed the purpose of the visit with General Manger Jill Johnson. According to the facility’s license, the facility has a maximum capacity of one hundred (100) residents eighty five (85) of whom may be non-ambulatory and fifteen (15) may be bedridden.This facility does not feature a secured perimeter or delayed egress doors. LPA's, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA's interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with General Manager Jill Johnson, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Sep 18, 2025

Type of visit: Case Management - Other

Licensing Program Managers (LPMs) Simon Jacob and Sabel Martinez conducted an unannounced Case Management visit to deliver an “Order to Licensee/Facility of Immediate Exclusion from Facility” for Staff #1 (S1 – see Confidential Names List). LPMs Simon Jacob and Sabel Martinez identified themselves and was granted entry by Senior General Manager Lori Hansen and met with Vice President of Operations David Tamo. The Department of Social Services, Community Care Licensing Division, orders MG AT Bankers Hill, LP;Shi-IV Merrill GP,LLC; Et Al, to remove S1 from any contact with residents or presence of S1 in all facilities associated. This exclusion letter is in result of an investigation by the California Department of Social Services, a complaint of conduct inimical has been found to be substantiated against an employee, by the name of S1. The Department has determined that continued or future contact with residents or presence in any child day care or residential facility licensed by the California Department of Social Services constitutes a threat to the health and safety of the residents in care. During the visit, LPMs confirmed that S1 was present at the facility. LPMs provided S1 with their exclusion letter and informed them it was an immediate exclusion. S1 left the facility premises prior to LPMs departure. LPMs spoke with Vice President of Operations David Tamo and provided him with their exclusion letter. There were no immediate health and safety concerns observed. An exit interview was conducted with Mr.Tamo, to whom a copy of this report, exclusion letter, LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 01/16) were provided. A copy this report was emailed to Vice President of Operations David Tamo and he confirmed receipt..the state’s words, verbatim · CDSS document, Jun 25, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management visit to amend a report for a visit conducted on 09/26/2023. LPA identified themselves and discussed the purpose of the visit with Senior General Manager Lori Hansen. During today’s visit, LPA obtained signatures on the amended report. No deficiencies were cited during the facility visit. An exit interview was conducted with Senior General Manager Lori Hansen, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 21, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Amy Domingo, conducted an unannounced Case Management visit. The LPA introduced himself and disclosed the purpose to Marketing Director, Dayna Farris and Med Tech, Jessica Ortiz and later with Lori Hansen Senior General Manager. Today's visit was in response to an Incident Report submitted to the Department, for Resident 1 (R1). [See LIC 811 Confidential Names List for a description of R1]. R1 sustained a fall on 04/02/2024, was transported to the hospital and passed away on 04/02/2024. The LPA conducted a tour of the facility and secured pertinent records. No health and safety concerns were identified and no deficiencies were cited during today's visit. An exit interview was conducted with Senior General Manager Lori Hansen, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 12, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Med Tech Jessica Ortiz and later during the visit with Executive Director Lori Hansen. According to the facility’s license, the facility has a maximum capacity of one hundred (100) residents. During today’s inspection, there were a total of eight nine (89) residents in care, and per medical records, all were ambulatory with one (1) resident bedridden. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 72 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 115 F, Bathroom #1 sink was 112 F, and Bathroom #2 sink was 115 F. Refrigerator temperature was 35 F and freezer temperature was 0 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Senior General Manager Lori Hansen, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Apr 12, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with General Manager Lori Hansen. LPA also met with Resident Service Director Kelly Biondo during the visit. Today's visit was in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 01/26/2024. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 01/20/2024. During today’s visit, LPA performed a brief facility tour and welfare check on remaining residents, finding no safety concerns. LPA also collected copies of and reviewed pertinent records and interviewed relevant staff. Per review of care records: R1 moved into the facility in May 2023. At that time, Licensee had obtained a recent Medical Assessment (i.e., an LIC602 Physician’s Report dated 04/18/2023) on R1. However, the LIC602 did not indicate whether a test for tuberculosis (TB) was performed on R1. LPA asked multiple managers if there was some other written record of R1 having a negative TB test result from the time of their move-in, but none could be produced during today’s visit. Staff interviews confirmed that R1 did not exhibit TB symptoms during their stay at the facility. Nothing in R1’s internal or external care records, which LPA reviewed today, suggested that R1 was ever infected with TB during their stay at the facility. R1 had a subsequent chest X-ray on 01/02/2024, which did not show evidence of TB. Per R1’s official Death Certificate, their death was unrelated to TB. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPA also issued one (1) Technical Violation (TV) regarding reporting requirements (see the LIC 9102-TV page). An exit interview was conducted with Hansen, to whom a copy of this report, the LIC809-D, the LIC9102-TV, and the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Feb 1, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(b)(1) · Plan of correction due date: Mar 2, 2024

87458 Medical Assessment: “(b) The medical assessment shall include…: (1) A physical examination of the resident…and results of an examination for communicable tuberculosis…” This requirement was not met, as evidenced by: Based on records review and manager interview: Licensee did not ensure that the medical assessment for 1 of 89 residents (R1) included the results of an examination for communicable tuberculosis, which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: As of the date of deficiency issuance, R1 had already passed away. Licensee agreed to implement a process whereby the facility representative who signs the admissions agreement with a residents’ responsible person also personally double-checks that said resident’s LIC602 Physician’s Report is signed and complete, as they are scheduling the contract signing meeting. Licensee also agreed to retrain all facility staff who are directly involved with the admissions/move-in process on Regulation 87458, titled “Medical Assessment,” and to submit the training sign-in sheet to LPA, by the POC due date.