Merrill Gardens at Santa Maria

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Sep 17, 2025

Allegation investigated: Staff threatened resident with eviction.

At 9:00am, on 9/10/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to investigate the allegation of this complaint. LPA met with Health Services Director Debra Gonzales, announced who he was and the reason for the visit. During the visit from 9:50am to 12:08pm LPA interviewed resident, staff, administrator, and collected documentation. On allegation, staff threatened resident with eviction. It was alleged that Resident #1 (R1) and the Administrator Michael Easbey had a conversation on 9/3/2025 and later that day the administrator came to R1’s apartment and told R1 “I want you outta here”. R1 understood this as an eviction notice, R1 did not receive a written eviction notice. (Continued on LIC9099-C) Unsubstantiated 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.the state’s words, verbatim · CDSS document, Sep 10, 2025 · control 29-AS-20250904140440

Allegation investigated: Facility did not meet resident's needs Facility did not seek timely medical attention for resident

On 05/07/2025 at 10:30 a.m. Licensing Program Analyst (LPA) Rankin conducted a 10-day complaint visit to the facility above. LPA met with Michael Easbey, Administrator and explained the purpose of the visit. During the investigation, LPA Rankin observed the facility, toured Resident 1’s (R1) room, collected relevant documentation, interviewed administrator, staff, residents, and spoke with a responsible party for R1. On the allegations: Facility did not meet resident's needs and facility did not seek timely medical attention for resident. It was alleged on 05/01/2025 the facility failed to provide checks to R1. Allegations stated that R1 was found in their room lying in bodily fluid, they were unresponsive to questions, and that there was discharge coming from residents’ eyes. It was stated the concerns were that staff was unaware of when R1 was last checked and that R1 was laying in their bed in the condition noted above for many hours without staff check ins. Continued on 9099-C Unsubstantiated 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 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.the state’s words, verbatim · CDSS document, May 7, 2025 · control 29-AS-20250506094736

Type of visit: Case Management - Annual Continuation

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 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 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.the state’s words, verbatim · CDSS document, Sep 5, 2024

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Aug 27, 2024

Allegation investigated: Facility is in disrepair.

Licensing Program Analysts (LPAs) Erika Miler and Jenny Olson conducted an unannounced 10-day complaint visit and to issue final findings on the allegation above. During the investigation, LPAs toured the facility and interviewed Administrator, staff, and residents on January 25, 2024 from 10:30 am to 2:00 pm. LPAs also obtained and reviewed relevant documents. LPAs met with Audie Sherberg and explained the purpose of the visit. On the allegation: Facility is in Disrepair Reporting party (RP) advised that the handicap door entry button in building 1350, has not been working for about six to eight weeks. A sign was left on the door that states the door will be repaired "tomorrow". RP stated that maintenance has been contacted and has advised that a part is on order. The door is almost impossible for some people on walkers or in mobile wheelchairs to open and enter the door without assistance from others. In addition, there is water leaking for the top of the door frame, so facility added a sign and a caution cone, that made it more difficult to navigate. Substantiated On January 25, 2024, LPAs interviewed six residents, three of the six stated that they could not open the door without assistance. A resident indicated that the 1350 handicap button was not working and took more than 3 weeks to resolve this issue. Resident advised that they could enter through the dinning room door, but when locked had to walk around the entire building to gain access. Another resident advised that the dryer on the second floor in Building 1220 has been broken since December 15, 2023 and remains out of service. LPAs observed a sign on the dryer that advised as such. A new dryer was delivered and ready to be installed. In addition, LPAs also observed a sign on the back gate near the pool patio, that stated, gate lock does not operate from outside. LPAs interviewed maintenance director, who provided work orders that reflected a timeline of incidents and actions taken. Maintenance director also advised that water leakage from an air conditioning unit above an entry door is currently being repaired and repairman was on site January 25, 2024. Interviews and record review revealed that facility attempted to resolve all issues in a timely manner. Based on the information obtained, the allegation is deemed substantiated at this time. A Technical Violation was issued as the facility attempted to mitigate the disrepair timely. Exit interview, report given, and appeal rights.the state’s words, verbatim · CDSS document, Jan 25, 2024 · control 29-AS-20240118165915

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Olson conducted a Case Management - Incident visit to issue deficiencies on an elopement the facility self-reported. LPA and met with Audie Sherberg, Administrator and explained the purpose of the visit. CCL received an incident report on 10/30/23 stating that on 10/28/23 Staff discovered Resident 1 (R1) was missing from Memory Care around 6:55 pm and could not locate them. Staff called 911 and conducted a search throughout the community, outside the community and surrounding areas. At around 7:21 pm Santa Maria Police Department called to say R1 was found and was taken to the hospital for evaluation. Resident was found on the corner of Rose and Suey Rd. and the paramedics were called because R1 fell. A CT was done and R1 was admitted for a Brain Bleed. LPA received a call/voicemail from the Garden House Director on Sunday 10/29/23 at 9:02 am explaining what happened. Administrator called LPA Monday 10/30/23 and stated R1 was on blood thinners which lead to the brain bleed, was doing well and no longer in the ICU and will be coming back to the facility soon. Administrator stated they are not sure how R1 got out of the double locked doors of the home and the locked fence. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). An immediate $500 civil penalty was assessed due to the resident being injured during their elopement. An exit interview was conducted, a copy of the report, Civil Penalty, and appeal rights were issued.the state’s words, verbatim · CDSS document, Nov 13, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 13, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ,,,(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when staff did not ensure R1’s safety when they wandered away from the facility which resulted in a fall and brain bleed, which posed an immediate health and safety risk tothe state’s words, verbatim · CDSS document, Nov 13, 2023

Plan of correction: Garden House Director conducted training to all Garden House staff and provided documentation to LPA. POC was cleared durring the visit resident in care.

Type of visit: Case Management - Annual Continuation

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.the state’s words, verbatim · CDSS document, Oct 4, 2023