Inspection Reports for Merrill Gardens at Monterey

200 Iris Canyon Rd, Monterey, CA 93940, CA, 93940

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Inspection Report Summary

Most inspections found no deficiencies, including the most recent annual inspection on May 21, 2025, which was clean and showed the facility to be safe, clean, and well-maintained. Earlier reports included some deficiencies related primarily to medication management and resident care, such as a medication error in July 2024 that resulted in hospitalization and failure to assist residents with activities of daily living substantiated in January 2024. Other issues involved incomplete medical assessments and communication lapses, but these were isolated and addressed. Several complaint investigations were unsubstantiated, including concerns about elevator safety, food service, and resident treatment. The facility’s record shows improvement over time, with recent inspections free of deficiencies and no enforcement actions or fines listed in the available reports.

Deficiencies (last 6 years)

Deficiencies (over 6 years) 1 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

75% better than California average
California average: 4 deficiencies/year

Deficiencies per year

4 3 2 1 0
2020
2021
2022
2023
2024
2025

Census

Latest occupancy rate 100% occupied

Based on a May 2025 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Census over time

80 100 120 140 160 Dec 2020 May 2022 Aug 2023 Mar 2024 Jul 2024 May 2025

Inspection Report

Annual Inspection
Census: 150 Capacity: 150 Deficiencies: 0 Date: May 21, 2025

Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing requirements at Merrill Gardens at Monterey.

Findings
The facility was found to be in good condition with no deficiencies issued. Resident rooms, common areas, dining, kitchen, medication storage, and outdoor areas were all observed to be safe, clean, and properly maintained.

Report Facts
Fire extinguisher service date: Jan 2, 2025 Last fire drill date: Apr 16, 2025 Refrigerator temperature: 35 Freezer temperature: 0 Hot water temperature: 112

Employees mentioned
NameTitleContext
Tiffaney SantoroAdministratorMet with Licensing Program Analyst during inspection
Vadim GorbanLicensing Program AnalystConducted the inspection
Brenda ChanLicensing Program ManagerNamed in report header

Inspection Report

Complaint Investigation
Census: 115 Capacity: 150 Deficiencies: 0 Date: Dec 14, 2024

Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2024-05-31 regarding staff qualifications, resident assessments, food service, activities, cleanliness, appointment reminders, shower assistance, pet care, and meeting residents' needs.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included unqualified staff left in charge, improper resident assessments, inadequate resident checks, insufficient food service, lack of activities, unclean rooms, failure to remind about appointments, failure to ensure showers, failure to care for resident's dog, and failure to meet residents' needs. None were substantiated based on evidence gathered.
Findings
All allegations investigated were found to be unsubstantiated due to lack of preponderance of evidence. Interviews with residents and staff, review of documentation, and observations indicated that staff were qualified, residents were properly assessed, food service was adequate, activities were provided, rooms were kept clean, appointments were managed, showers were given as requested, pets were not the facility's responsibility, and residents' needs were met.

Report Facts
Capacity: 150 Census: 115 Complaint receipt date: May 31, 2024

Employees mentioned
NameTitleContext
Sarah HurtLicensing Program AnalystConducted the complaint investigation visit and authored the report
Jaime RiosSenior Executive ChefMet with Licensing Program Analyst during the investigation and participated in exit interview
Tiffaney SantoroAdministratorFacility administrator named in the report

Inspection Report

Complaint Investigation
Census: 112 Capacity: 150 Deficiencies: 0 Date: Jul 27, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not ensure the elevator was in good repair and that special food service was not served with accuracy for residents in care.

Complaint Details
The complaint investigation was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred. The elevator issue was temporary and managed appropriately, and the food service was delivered accurately.
Findings
The investigation found that although there was an issue with one elevator being out of service temporarily, another elevator was available and accommodations were made for residents. The food service delivery during the elevator outage was reported to be prompt and accurate. There was insufficient evidence to substantiate the allegations, and no deficiencies were cited.

Report Facts
Capacity: 150 Census: 112

Employees mentioned
NameTitleContext
Sarah HurtLicensing Program AnalystConducted the complaint investigation
Jaime RiosExecutive ChefMet with the Licensing Program Analyst during the investigation and participated in the exit interview
Tiffaney SantoroAdministratorProvided information regarding the elevator issue
Brenda ChanLicensing Program ManagerNamed in the report as Licensing Program Manager

Inspection Report

Census: 110 Capacity: 150 Deficiencies: 1 Date: Jul 17, 2024

Visit Reason
The visit was an unannounced Case Management inspection conducted to review facility compliance and investigate a reported medication error.

Findings
The facility reported a medication error where Resident 1 was given medication intended for another resident, resulting in hospitalization. Staff involved received training and were removed from medication technician in training duties. Deficiencies were cited related to incidental medical and dental care per Title 22 regulations.

Deficiencies (1)
Resident 1 was given incorrect medication on 07/11/2024 resulting in a hospital visit, posing an immediate health, safety, or personal rights risk to residents in care.
Report Facts
Deficiencies cited: 1

Employees mentioned
NameTitleContext
Tiffaney SantoroAdministratorMet with Licensing Program Analyst during inspection and named in report
Sarah HurtLicensing Program AnalystConducted the unannounced visit and authored the report
Brenda ChanLicensing Program ManagerNamed as supervisor in the report

Inspection Report

Annual Inspection
Census: 110 Capacity: 150 Deficiencies: 1 Date: May 28, 2024

Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations.

Findings
The facility was generally found to be clean, safe, and well-maintained with proper emergency preparedness. However, two residents with dementia did not have the required annual medical assessment and reappraisal completed as mandated by Title 22 regulations.

Deficiencies (1)
Two residents with dementia did not have an annual medical assessment and reappraisal completed as required by Title 22 regulations.
Report Facts
Residents without required annual medical assessment: 2 Total resident files reviewed: 10 Plan of Correction Due Date: May 31, 2024

Employees mentioned
NameTitleContext
Tiffaney SantoroExecutive DirectorMet with Licensing Program Analyst during inspection and agreed to plan of correction.
David AyersLicensing Program AnalystConducted the inspection and authored the report.
Brenda ChanLicensing Program ManagerNamed as Licensing Program Manager overseeing the inspection.

Inspection Report

Complaint Investigation
Census: 122 Capacity: 150 Deficiencies: 0 Date: Mar 7, 2024

Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 2024-02-28 regarding a resident being trapped in the elevator due to the facility not obtaining back-up power.

Complaint Details
The complaint alleged a resident was trapped in the elevator due to lack of back-up power. The allegation was unsubstantiated after investigation.
Findings
The investigation found that on 2024-02-04, a resident was trapped in the elevator for approximately two hours during a power outage. The elevator was opened by emergency responders, was properly serviced and maintained, and no resident was injured. The allegation was unsubstantiated due to lack of preponderance of evidence.

Report Facts
Capacity: 150 Census: 122 Complaint Control Number: 24-AS-20240228154207

Employees mentioned
NameTitleContext
David AyersLicensing Program AnalystConducted the complaint investigation
Amor SoriusSenior Business Office DirectorMet with Licensing Program Analyst during inspection
Tiffaney SantoroAdministratorFacility administrator named in report header

Inspection Report

Complaint Investigation
Census: 114 Capacity: 150 Deficiencies: 1 Date: Jan 4, 2024

Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 2023-11-15 regarding allegations that facility staff were not assisting residents with activities of daily living and not meeting the needs of residents in care.

Complaint Details
The complaint was substantiated based on interviews, observations, and records review. The allegations that staff were not assisting residents with activities of daily living and not meeting residents' needs were confirmed.
Findings
The investigation substantiated that facility staff were not assisting residents with eating and other activities of daily living as required by California Code of Regulations Title 22. At least one resident out of 114 was not provided necessary assistance, presenting a risk to health and safety.

Deficiencies (1)
Failure to provide personal assistance and care as needed by the resident, including assistance with activities of daily living such as dressing, eating, bathing, and medication administration.
Report Facts
Census: 114 Total Capacity: 150 Deficiencies cited: 1 Plan of Correction Due Date: Jan 12, 2024

Employees mentioned
NameTitleContext
David AyersLicensing Program AnalystConducted the complaint investigation and authored the report
Brenda ChanLicensing Program ManagerOversaw the complaint investigation
Tiffaney SantoroExecutive DirectorFacility administrator met during inspection and agreed to provide staff training

Inspection Report

Complaint Investigation
Census: 114 Capacity: 150 Deficiencies: 2 Date: Jan 4, 2024

Visit Reason
The inspection was conducted to address deficiencies observed during the investigation of a complaint received on 2023-11-15 against the facility.

Complaint Details
The visit was complaint-related, investigating complaint control number 24-AS-20231115122107 received on 2023-11-15. The deficiencies were substantiated as described.
Findings
The inspection found that the facility failed to include the responsible party in a resident reappraisal conducted on 2023-11-19, and failed to provide timely written notice of a rate increase to the resident's representative within two business days after a change in level of care.

Deficiencies (2)
Failure to include the responsible party in a resident reappraisal after a significant change in condition.
Failure to provide written notice of a rate increase to the resident's representative within two business days after a change in level of care.
Report Facts
Capacity: 150 Census: 114 Plan of Correction Due Date: Jan 12, 2024

Employees mentioned
NameTitleContext
Tiffaney SantoroExecutive DirectorMet with Licensing Program Analyst during inspection.
David AyersLicensing Program AnalystConducted the inspection and delivered complaint findings.
Brenda ChanLicensing Program ManagerSupervisor overseeing the inspection.

Inspection Report

Complaint Investigation
Census: 116 Capacity: 150 Deficiencies: 0 Date: Aug 29, 2023

Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2023-05-26 regarding allegations of staff sharing resident's personal information and failure to prevent resident intimidation.

Complaint Details
The complaint involved allegations that facility staff shared a resident's personal information with another resident and that staff did not prevent a resident from intimidating others. The allegations were unsubstantiated due to lack of corroborating evidence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff denied sharing personal information, and witnesses denied resident intimidation. The facility was toured to ensure no immediate health or safety risks were present.

Report Facts
Capacity: 150 Census: 116

Employees mentioned
NameTitleContext
Tiffaney SantoroExecutive DirectorMet with Licensing Program Analyst during complaint investigation
David AyersLicensing Program AnalystConducted the complaint investigation
Brenda ChanLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Census: 116 Capacity: 150 Deficiencies: 0 Date: Aug 28, 2023

Visit Reason
Unannounced complaint investigation conducted due to a complaint received on 05/25/2023 regarding unlawful eviction.

Complaint Details
The complaint was unsubstantiated based on interviews, documentation, and investigation findings. The resident was not accepted back due to medical requirements, not unlawful eviction.
Findings
The investigation found that the allegation of unlawful eviction was unsubstantiated. The facility was unable to accept a resident back due to the resident having an indwelling catheter, which is against regulatory requirements.

Report Facts
Capacity: 150 Census: 116

Employees mentioned
NameTitleContext
Tiffaney SantoroExecutive DirectorMet with Licensing Program Analyst during complaint investigation
David AyersLicensing Program AnalystConducted the complaint investigation
Brenda ChanLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Annual Inspection
Census: 108 Capacity: 150 Deficiencies: 0 Date: May 3, 2023

Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations.

Findings
The facility was found to be in compliance with no deficiencies cited. The inspection included a tour of the facility, review of emergency preparedness, medication storage, resident and staff files, and verification of safety features.

Report Facts
Capacity: 150 Census: 108

Employees mentioned
NameTitleContext
Tiffaney SantoroAdministratorMet with Licensing Program Analyst during inspection and named in report
David AyersLicensing Program AnalystConducted the inspection
Brenda ChanLicensing Program ManagerNamed in report

Inspection Report

Complaint Investigation
Census: 108 Capacity: 150 Deficiencies: 0 Date: Dec 9, 2022

Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 05/08/2020 regarding inadequate fluid provision, falsification of medication administration records and medication label instructions, and failure to administer medications according to physician orders.

Complaint Details
Complaint received on 05/08/2020 with allegations including inadequate fluids to residents, falsification of medication administration records, falsification of medication label instructions, and failure to administer medications according to physician orders. The first three allegations were unsubstantiated; the last was substantiated with documented medication errors for Resident 1 and Resident 2.
Findings
The investigation found the allegations of inadequate fluid provision, falsification of medication administration records, and falsification of medication label instructions to be unsubstantiated based on interviews with staff and residents. However, the allegation that staff did not administer medications according to physician orders was substantiated with documented medication errors for two residents in April and May 2020. No deficiencies were cited per Title 22 Regulations.

Report Facts
Capacity: 150 Census: 108

Employees mentioned
NameTitleContext
Sarah HurtLicensing Program AnalystConducted the complaint investigation and delivered findings
Tiffany SantoroAdministratorMet with Licensing Program Analyst during the investigation and exit interview

Inspection Report

Follow-Up
Census: 100 Capacity: 150 Deficiencies: 1 Date: May 9, 2022

Visit Reason
The visit was a Case Management follow-up on an incident report regarding medication administration.

Findings
The Licensing Program Analyst found that a resident (R1) did not receive their prescribed medication due to the licensee receiving another resident's medication, posing an immediate health, safety, or personal rights risk.

Deficiencies (1)
Failure to assist residents with self-administered medications as needed, evidenced by Licensee not giving R1's prescribed medication due to receiving R2's medication, posing an immediate health, safety, or personal rights risk.
Report Facts
Deficiency due date: Jun 10, 2022

Employees mentioned
NameTitleContext
Tiffaney SantoroAdministratorMet with Licensing Program Analyst during visit and involved in exit interview
Sergiy PidgirnyLicensing Program ManagerNamed as supervisor and licensing program manager
Shawna DoucetteLicensing Program AnalystConducted the case management visit and signed the report

Inspection Report

Complaint Investigation
Census: 102 Capacity: 150 Deficiencies: 0 Date: Mar 30, 2022

Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2021-07-08 regarding staff treatment of residents, garbage container covers, and insect presence.

Complaint Details
The complaint was unsubstantiated based on interviews, observations, and record reviews. Allegations included staff not treating residents with dignity, garbage containers lacking tight fitting covers, and presence of insects.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff treatment of residents with dignity was unknown, garbage containers had tight fitting covers, and the facility was actively treating insect problems with pest control services.

Report Facts
Complaint Control Number: 26 Capacity: 150 Census: 102

Employees mentioned
NameTitleContext
Shawna DoucetteLicensing Program AnalystConducted the complaint investigation and delivered findings
Tiffaney SantoroAdministratorFacility administrator met during the investigation
Sergiy PidgirnyLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Complaint Investigation
Census: 102 Capacity: 150 Deficiencies: 0 Date: Mar 30, 2022

Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2021-10-25 regarding the emergency backup power not operating during a power outage.

Complaint Details
The complaint alleged that emergency backup power did not operate during a power outage. The allegation was unsubstantiated after investigation.
Findings
The investigation found that during the power outage lasting about 1.5 to 3 hours, the facility provided glow sticks, flashlights, flood lights, and checked on residents frequently. The facility has a contract for a backup generator for extended outages. The allegation was unsubstantiated due to lack of preponderance of evidence.

Report Facts
Complaint Control Number: 26 Complaint Received Date: Oct 25, 2021

Employees mentioned
NameTitleContext
Shawna DoucetteLicensing Program AnalystConducted the complaint investigation and delivered findings
Tiffaney SantoroAdministratorFacility administrator met during the investigation
Sergiy PidgirnyLicensing Program ManagerNamed in report signature section

Inspection Report

Annual Inspection
Census: 103 Capacity: 150 Deficiencies: 0 Date: May 24, 2021

Visit Reason
The inspection was an unannounced required 1-year infection control visit to evaluate compliance with infection control policies and procedures.

Findings
The facility was found to be in compliance with infection control regulations, with no citations issued. The inspection included a tour of the facility, review of policies, and observation of staff and resident practices related to infection control.

Report Facts
Capacity: 150 Census: 103

Employees mentioned
NameTitleContext
Marybeth DonovanLicensing Program AnalystConducted the infection control visit
Tiffaney SantoroGeneral ManagerMet with Licensing Program Analyst during the visit

Inspection Report

Census: 102 Capacity: 150 Deficiencies: 0 Date: Dec 16, 2020

Visit Reason
The visit was a Technical Assist (TA) conducted via Zoom to provide technical assistance for Infection Prevention and Control guidelines for Adult and Senior Care facilities.

Findings
The Licensing Program Analyst reviewed the facility's policies and procedures related to infection control, including screening, disinfecting, staffing, training, emergency medical care, PPE usage, and resident activities. Recommendations were made to improve PPE donning and doffing signage, hand sanitizing, trash disposal, and mask changing protocols.

Employees mentioned
NameTitleContext
Marybeth DonovanLicensing Program AnalystConducted the Technical Assist visit and reviewed infection prevention and control guidelines.
Tiffaney SantoroGeneral Manager/AdministratorMet with Licensing Program Analyst during the visit and reviewed the report.
Ruby PerezDirector of ActivitiesParticipated in the Technical Assist visit.
Barbara ElentenyProgram Clinical Consultant NurseParticipated in the Technical Assist visit.
Lauren M. PowellAdministratorNamed as facility administrator.

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