198320089-9-14-2024-11-AS-EDAT-D94TJV-20240914144659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320089
Report Date: 09/14/2024
Date Signed: 09/14/2024 02:47:41 PM

Document Has Been Signed on 09/14/2024 02:47 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 ESTATES		FACILITY NUMBER:	198320089
ADMINISTRATOR:	TRACEY E HOLDER		FACILITY TYPE:	740
ADDRESS:	627 SILVER SPUR RD		TELEPHONE:	(310) 974-3339
CITY:	ROLLING HILLS	STATE: CA	ZIP CODE:	90274
CAPACITY:	150	CENSUS: 93	DATE:	09/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:54 AM
MET WITH:	Tracey Holder		TIME COMPLETED:	03:07 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/14/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the General Manager Tracey Holder. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (150) non-ambulatory elderly adults of which (15) may be bedridden ages 60 and above. Currently, the facility has (93) residents and (9) in hospice care. The facility is approved for (15) hospice residents. The facility is a four-story structure located in a commercial neighborhood. It consists of the following: (114) resident bedrooms, (115) resident bathrooms and (7) public restrooms, staff lounge, staff restroom, (2) dining rooms, a movie theater, activity rooms, a Wellness room, a laundry room, business offices, a kitchen, outdoor patio, (62) parking spaces, and a Beauty Salon operated by a third party. The Garden House is the memory care unit. LPA Dabuet and General Manager Holder toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #101, #108, #119, #133, #211, #223, #310, #320 and #322, All call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.2 – 107.9 degrees F. A comfortable temperature was maintained in the facility at 72 - 74 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. The facility conducted monthly fire drills. The last fire drill was on 08/15/24. Evaluation Report continues LIC 809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ESTATES	FACILITY NUMBER: 198320089
	VISIT DATE: 09/14/2024

NARRATIVE

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Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including Activities Calendar and Food Menu.

LPA conducted an audit of resident #1-#6 (R1-R6) service files, and staff #1-#7 (S1-S7) personnel files were in order and complete. The facility is current in CCLD annual fees. The facility has a current administrator certificate for Tracey Holder # 7020086740 valid through 01/22/2025. The facility has a Liability Insurance Certificate valid 07/01/24 through 07/01/25.

No deficiencies during this visit.

An exit interview conducted with the General Manager Tracey Holder, and a copy of the report is provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024

LIC809 (FAS) - (06/04)

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