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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320089
Report Date: 02/07/2024
Date Signed: 02/07/2024 02:23:25 PM


Document Has Been Signed on 02/07/2024 02:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:MERRILL GARDENS AT ROLLING HILLS ESTATESFACILITY NUMBER:
198320089
ADMINISTRATOR:DEBBIE INFIELDFACILITY TYPE:
740
ADDRESS:627 SILVER SPUR RDTELEPHONE:
(310) 750-9877
CITY:ROLLING HILLSSTATE: CAZIP CODE:
90274
CAPACITY:150CENSUS: 114DATE:
02/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Tracy Mallaret/AdministratorTIME COMPLETED:
02:23 PM
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On 02/07/24, Licensing Program Analyst, LPA Alfonso Iniguez conducted a Case Management visit to follow up on the incident report that the department received on 2/5/24. LPA was greeted by Tracy Mallaret / Administrator and explained the purpose of the visit is to gather information surrounding the incident of (R#1).

The Regional Office (RO) received a copy of the Special Incident Report (SRI) from the facility and reported that (R#1) stated that they were drugged and sexually assaulted by facility staff (S#1).

The following documents and interviews were retrieved and conducted:

·Copy (R#1) records and hospital discharge papers.
·Interviews with Administrator (A#1), Staff (S#1) and residents (R#2-R#11)

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.



An exit interview was conducted, and a copy of this report was provided to Tracy Mallaret /Administrator.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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