198320089-11-11-2023-11-AS-AINZ-CXGVZ2-20231111155203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320089
Report Date: 11/11/2023
Date Signed: 11/11/2023 03:52:08 PM

Document Has Been Signed on 11/11/2023 03:52 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 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: 111	DATE:	11/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Tracey Mallaret/Administrator		TIME COMPLETED:	03:46 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 11/11/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Tracey Holder/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (150) non-ambulatory elderly adults ages 60 and above. of which (15) may be bedridden. Facility has an approved hospice waiver for (15).

The facility is a three-story structure located in a residential/commercial neighborhood. It consists of (114) bedrooms, (124) bathrooms, garage level floor- Lobby, reception area, administrators’ offices, lounge, computer area, Theater, Activity room and office, Discovery room, Soiled room and laundry room, storage room, Prep-Kitchen, Wellness room, Med room, Beauty salon, Refuge room, discovery room, 1st floor- Open Kitchen, Private dining room, Dining room. 2nd - Floor - lounge, refuge room. 3rd Floor - Refuge and housekeeping closet. Garden House (Memory Care Unit) - laundry room, med room, kitchen, dining room, and living room. Shaded back patio and underground parking.

LPA Iniguez toured the physical plant with Administrator. There were no bodies of water or obstructions on the premises. A total of (11) 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. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #120, #122, #132, #103(M), #106(M), #216, #211,#210, #222, #220 and #311; call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 107.5F° – 114.2F°. The rooms temperature ranged from 76F° – 78F°.

Evaluation Report continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2023

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 3

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
	VISIT DATE: 11/11/2023

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
26
27
28
29
30
31
32

LPA Iniguez observed the facility to be sanitary and appropriately 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 there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 10/27/23. Annual fire clearance performed on 11/22/2022. Working landline phones are available on-site. A review of (6) residents' service files and (6) staff personnel files and (3) Medication Administration Records (MAR) were observed.

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 throughout the facility. A copy of liability insurance was provided to LPA during visit.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. (See D page)

An exit interview was conducted, and a copy of the Facility Evaluation Report and Appeal Rights was provided to the Administrator/ Tracey Holder.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 11/11/2023 03:52 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: 11/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(6)

87465 Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in staff not documenting when giving medication to residnet's family which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/27/2023
	Plan of Correction
1 2 3 4	Licensee will ensure al staff who handles medication will document when giving medications to resident's family. In addition, licensee will re-train staff about documenting medications in the MAR. Licensee will send proof of traininig to LPA before POC due date via email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3