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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603348
Report Date: 12/27/2022
Date Signed: 12/27/2022 11:23:18 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2022 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221220102958
FACILITY NAME:MERRILL GARDENS AT WEST COVINAFACILITY NUMBER:
198603348
ADMINISTRATOR:FISCHER, SHERRYFACILITY TYPE:
740
ADDRESS:1400 WEST COVINA PKWYTELEPHONE:
(206) 676-5300
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY:150CENSUS: 103DATE:
12/27/2022
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Sherry Fischer (Administrator)TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident is financially abusing another resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted a complaint investigation at the facility. Upon arrival, LPA met with Sherry Fischer (Administrator) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff/Resident rosters, Resident #1's Physician report and Capability Evaluation, interviewed Staff #1 in the conference room and attempted to interviewed Resident #1 (R#1) and Resident #2 (R#2).

In regards to the allegation: Resident is financially abusing another resident in care. LPA reviewed R#1's Physician report which indicate R#1 is able to manage own cash resources. A review of R#1's Capability Evaluation indicate R#1 has no impairments in regards to making own decisions. Interview with Staff #1 indicate R#1 is capable of handling R#1's finances and is not aware if R#1 is a victim of financial abuse. Interviews with R#1's family members indicate there is no proof of financial abuse but suspect potential future financial abuse. Continue to LIC9099....
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20221220102958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/27/2022
NARRATIVE
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Based on LPA's interviews and record review, the investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted with Sherry Fischer and a copy of this report provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2