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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320089
Report Date: 01/30/2023
Date Signed: 01/30/2023 04:13:48 PM


Document Has Been Signed on 01/30/2023 04:13 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



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: 106DATE:
01/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:WILL CARTERTIME COMPLETED:
04:30 PM
NARRATIVE
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On 1/30/2023, LPA Lourdes Montoya conducted a case management - deficiency visit. LPA met with Administrator Will Carter who assisted with the visit.

LPA observed the following deficiency during an unrelated complaint visit.

The kitchen is on two floors (parking level and first floor). The kitchen appliances, walls, floors, and counters on both floors are dirty.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed a deficiency and issued a citation.

An exit interview was conducted with Administrator Will Carter, and a hard copy of the report and Appeal Rights provided.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/30/2023 04:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: MERRILL GARDENS AT ROLLING HILLS ESTATES
FACILITY NUMBER: 198320089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/13/2023
Section Cited

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This was not met as evidenced by:
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Administrator shall ensure the kitchen is always clean and sanitary. Administrator will send a proof of corrections to CCLD via email to lourdes.montoya@dss.ca.gov by the due date.
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LPA Montoya observed and took photos of the kitchen which is located on two floors (parking level and first floor). The kitchen appliances, walls, floors, and counters on both floors are dirty.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2