198320089-10-19-2023-11-AS-MVAO-D3YV5S-20240403160825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320089
Report Date: 10/19/2023
Date Signed: 10/19/2023 12:12:40 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2022 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221116170557

FACILITY NAME:	MERRILL GARDENS AT ROLLING HILLS ESTATES		FACILITY NUMBER:	198320089
ADMINISTRATOR:	DEBBIE INFIELD		FACILITY TYPE:	740
ADDRESS:	627 SILVER SPUR RD		TELEPHONE:	(310) 750-9877
CITY:	ROLLING HILLS	STATE: CA	ZIP CODE:	90274
CAPACITY:	150	CENSUS: 112	DATE:	10/19/2023
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Tracey Mallaret		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility staff did not provide residents current medical records to emergency personnel.
Facility staff did not report incident accurately.
Staff did not dispense medication as prescribed.

INVESTIGATION FINDINGS:

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On 10/11/23, at 9:40am, Licensing Program Analyst (LPA) Perry Scott conducted a subsequent complaint investigation to obtain additional information regarding the allegations listed above. LPA met with Tracey Mallaret, General Manager, and explained the purpose of today’s visit.

The investigation consisted of the following:

During today’s visit LPA toured the facility. LPA requested the following records: Resident roster, staff roster, resident record (Physicians report, ID/Emergency Information, Showering Schedule, Staff training in transferring/Fall Risk for residents, Call Log, Assessment and Needs Plan, Preplacement Appraisal Plan, MAR, and Progress notes). LPA interviewed staff (S1-S5) and residents (R1-R10).

The investigation revealed the following- Allegation # 1 Facility staff did not provide residents current medical records to emergency personnel.

Report continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 11-AS-20221116170557

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MERRILL GARDENS AT ROLLING HILLS ESTATES	FACILITY NUMBER: 198320089
	VISIT DATE: 10/19/2023

NARRATIVE

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On 10/11/23, from 09:40am-2:00pm, LPA interviewed S1-S5. It is alleged that the staff did not provide the Emergency Medical Team with current medical records when R1 was transported to the hospital. 5 of 5 staff denied the allegation that the Facility staff did not provide residents current medical records to emergency personnel. All staff stated that it is protocol to give 911 packets to the EMT when a resident is transported by emergency services. S1 stated that “the Med-Tech, nurse, or the front desk will supply the EMT with the 911 packets for the resident. This is always done and was done the night the resident R1 fell on 10/21/22. R1 passed away on 10/29/22 and was not interviewed.

Based on interviews, there is insufficient evidence to support the allegation that Facility staff did not provide residents current medical records to emergency personnel. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation # 2 Facility staff did not report incident accurately.

On 10/11/23, from 09:40am-2:00pm, LPA interviewed S1-S5. It is alleged that the facility falsified reports claiming that they responded to a pendant call (Call for help) for R1. 3 of 5 staff (S1-S3) denied the allegation that Facility staff did not report incident accurately; while one staff (S4) was not working at the facility at the time, and the other (S5) had no knowledge of the incident. S1-S3 stated that the family members alerted staff that R1 had fallen. Upon being alerted, the staff called 911 for further assistance. S1-S3 stated that there was not a pendant call for help by R1 and it wasn’t documented as it was. LPA reviewed documentation of pendant alarm activity for R1 on 10/21/22, and no calls were made on that date. The last call logged was on 10/19/22 at 12:41am.

Based on interviews and a records review, there is insufficient evidence to support the allegation that Facility staff did not report incident accurately. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation # 3 Staff did not dispense medication as prescribed.

On 10/11/23, from 09:40am-2:00pm, LPA interviewed S1-S5 & R1-R10. It is alleged that the facility failed to dispense medication as prescribed. 5 of 5 staff denied the allegation that Staff did not dispense medication as prescribed.

Report continued on LIC9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20221116170557

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MERRILL GARDENS AT ROLLING HILLS ESTATES	FACILITY NUMBER: 198320089
	VISIT DATE: 10/19/2023

NARRATIVE

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All staff stated that all medication administered for R1 was documented and given as prescribed by the physician. They further state that R1’s medication was documented in the residents’ Medication Administration Record. LPA reviewed the Medication Administration Records for R1 and did not observe any discrepancies. LPA interviewed R1-R10 about the allegation and 9 of 10 residents state that staff does dispense their medication as prescribed.

Based on interviews and a records review, there is insufficient evidence to support the allegation that Staff did not dispense medication as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were cited.

An exit interview was conducted, and a copy of this report was given to Tracey Mallaret, General Manager.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC9099 (FAS) - (06/04)

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