198603348-9-24-2020-28-AS-DSIS-BTRVKU-20200924163054

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603348
Report Date: 09/24/2020
Date Signed: 09/24/2020 04:31:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	MERRILL GARDENS AT WEST COVINA		FACILITY NUMBER:	198603348
ADMINISTRATOR:	FISCHER, SHERRY		FACILITY TYPE:	740
ADDRESS:	1400 WEST COVINA PKWY		TELEPHONE:	(206) 676-5300
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY:	150	CENSUS: 0	DATE:	09/24/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Sherry Fischer; Executive Director		TIME COMPLETED:	03:00 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	Licensing Program Analyst (LPA) David Sicairos conducted an announced pre licensing visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted via Zoom with Executive Director Sherry Fischer. The facility has a fire clearance from the local Fire Department approved for 150 non-ambulatory residents of which 15 may be bedridden. Memory Care Unit approved for delayed egress, secured perimeter, and secured locked perimeter. Hospice Waiver approved for 15 residents. There are a total of 111 apartments, 13 of those in memory care unit and 2 of those 13 apartments will be shared. The following areas were inspected during the televisit tour of the physical plant with the Executive Director: Mailroom, Beauty Salon, Exercise Room, Med Room, Movie Theater, Activity Room, Dining Room, Kitchen, and Memory Care Unit. This is a 5 story building and a random sample of apartments were inspected on each floor. Resident apartments have the required furniture with sufficient closet space. Bathrooms were clean, toilets and water faucets worked properly and were properly supplied, have functional fixtures, and have secure grab bars. Emergency pull cords were observed in every resident apartment. Showers were free of mold/ mildew and non-skid mats or strips were properly in place. Water temperature was measured in various different resident apartments throughout the facility and measured between 110.3F - 114.4F which falls within Title 22 Regulations. A locked storage area for central storage of medications were observed in both medication rooms. The walls, ceilings, floors, window screens and areas around the facility were clean and in good repair. Several fire extinguishers were observed throughout the facility. Smoke detectors were observed throughout the facility along with attached carbon monoxide detectors. Doors, exits, hallways, and passageways were clear and free of obstruction. There are no pools or bodies of water in or around the facility. Emergency Exit Plan and Emergency Phone Numbers were observed to be posted in appropriate places. A current disaster and mass casualty plan is maintained at the facility. An operating telephone was observed on the premises, which is easily accessible and available for client use. (CONTINUED ON 809C)

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2020

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERRILL GARDENS AT WEST COVINA	FACILITY NUMBER: 198603348
	VISIT DATE: 09/24/2020

NARRATIVE

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Several first aid kits were observed throughout the faciltiy which included all required supplies. The refrigerators was observed to be at 45 degrees Fahrenheit and the freezer at 0 degrees Fahrenheit.

Food storage and preparation areas, which includes pantries, cupboards, drawers and counters were observed to be clean and appropriate for food preparation. Appliances such as a microwaves, refrigerators, and stoves were observed to be clean and operating properly. Food utensils were clean and sufficient for the number of residents to be served. The outdoor patio areas were observed to have well shaded areas and were furnished for outdoor use.

No outstanding or pending items were observed by LPA requiring additional pre-licensing visits. LPA Sicairos will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation.

Exit interview conducted and a copy of this report was emailed to the Executive Director for signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2020

LIC809 (FAS) - (06/04)

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