198603348-9-10-2024-28-AS-NMAN-D8YTM7-20240910145041

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603348
Report Date: 09/10/2024
Date Signed: 09/10/2024 02:50:47 PM

Document Has Been Signed on 09/10/2024 02:50 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
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:	(626) 587-4318
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY:	150	CENSUS: 109	DATE:	09/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Patricia Colin		TIME COMPLETED:	03:00 PM

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Licensing Program Analysts (LPA) Nune Margaryan and Myra Cota conducted an unannounced annual visit using the Care Tool. LPAs met with Business Office Director Patricia Colin, who assisted with visit. LPAs explained the reason for the visit. The facility is licensed to RCFE/Dementia for age range 60 and over. Approved for 150 non-ambulatory, of which 15 may be bedridden, approved in rooms in memory care unit. Hospice Waiver approved for 15 residents.

The facility is a 5 story building. There are a total of 111 apartments: 98 rooms in AL Unit and 13 in Memory Care Unit and 2 of the 13 apartments are shared rooms. On the first floor (AL Unit), it included Receptionist/Front Desk, Staff Offices, Theater room/Activity Room, Resident Mailbox area, Salon/Spa Room, Maintenance Office, Wellness Center, Dining area, Facility Kitchen, Public bathrooms for Male and Female, Staff Lounge and Private Dining Room. Memory Care Unit (Garden House) is a secured building. It includes 13 residents rooms, living room, laundry room, public bathroom, medication room and office. A random sample of apartments were inspected on each floor/unit. Each resident apartment have the required furniture and sufficient lighting and closet space. The bathrooms are clean, sanitary and in a good working condition. All bathrooms have the required grab bar and non-skid mat. Water temperature was measured in various different resident apartments throughout the facility and measured between 113.1F - 115.3F which falls within Title 22 Regulations. A locked storage area for centrally stored medications were observed in both medication rooms (AL Unit and Memory Care Unit). Several first aid kits were observed throughout the facility which included all required supplies. The walls, ceilings, floors, windows, and areas around the facility were clean and in good repair. Several fire extinguishers were observed throughout the facility. LPAs also inspected the carbon monoxide detectors in the facility, and they are working properly.

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SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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
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: 09/10/2024

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Facility kitchen was inspected. All appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. Food supply adequate stored in the kitchen, storage room and consists of the following: 2 days perishable and 7 days non-perishable. Cleaning supplies and toxins were observed locked and inaccessible to residents. Doors, exits, hallways, and passageways were clear and free of obstruction. There are no pools or bodies of water in or around the facility. The outdoor patio areas were observed to have well shaded areas and were furnished for outdoor use. The last fire drill was conducted on 8/15/24.

LPAs reviewed 10 resident records to confirm emergency contact is updated, physician's reports are on file, and admission agreements are complete. 5 staff records were reviewed to confirm health screenings, training, and fingerprint clearances. LPAs reviewed 4 residents' medications. Medications are documented properly and given as prescribed.

No deficiencies were observed during today's visit.

Exit interview held. A copy of the report was provided to Business Office Director.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

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