198603348-10-6-2023-28-AS-CWOG-CWCVHQ-20231006162730

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603348
Report Date: 10/06/2023
Date Signed: 10/06/2023 04:28:31 PM

Document Has Been Signed on 10/06/2023 04:28 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
GREATER LA AC/SC, 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: 102	DATE:	10/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Monica Chavez		TIME COMPLETED:	04:45 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) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Activity Director Nicole Bermingham and shortly after the Resident Care Director Monica Chavez arrived and assisted LPA with 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. Currently, one (1) resident on hospice, zero (0) bedridden resident and three (3) residents on home health services. On today's date, LPA inspected the following domains which include: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Resident Records/Incident Reports, Resident's Right, Planned Activities, Food Service and Incident Medical and Dental. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirements: The current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 15 residents is approved. A fire clearance for 150 non-ambulatory residents; of which 15 may be bedridden is in place. Liability Insurance in the amount of at least ($5,000,000) per occurrence and total amount of aggregate ($5,000,000) is in place. 3. Physical Plant and Environmental Safety: The facility is a 5 story building. There are a total of 111 apartments, 13 of those in memory care unit and 2 of the 13 apartments will be shared. On the first floor, it included Receptionist/Front Desk, Staff Offices, Theater room/Activity Room, Resident Mail box, Salon/Spa Room, Maintenance Office, Wellness Center, Dining area, Facility Kitchen, Public bathroom for Male and Female, Staff Lounge and Private Dining Room. (See LIC 809C for continuation)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERRILL GARDENS AT WEST COVINA	FACILITY NUMBER: 198603348
	VISIT DATE: 10/06/2023

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

On the other side of the building and its included memory care unit (Garden House) and its a secured building. It includes 15 residents rooms, living room, laundry room, public bathroom, medication room and office. For the memory care unit, LPA inspected Room#100, #107 and #113. Each memory care 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. The hot water temperature in memory care residents apartments were tested between 114.9 and 115.8 degrees F and they are within the Title 22 regulation. From 2nd floor to 5th floor, they are all assisted living unit and independent living unit. LPA inspected Room#200 #202, #300 #315 #400 #415 and #506 and each resident apartment has 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. The hot water temperature were tested between 114.6 and 117.1 degrees F which is within the Title 22 regulation. LPA also inspected the carbon monoxide detectors in the facility and they are working properly.

4. Staffing: Facility has sufficient staffing for care and supervision to the residents.

5. Residents Records/Incident Reports: LPA inspected 12 residents files and they all have the required documents in file which included : admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records.

6. Resident's Right: LPA observed the required posters posted near the Theater Room which include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician.

7. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted and LPA reviewed the calendar for both Assisted Living and Memory Care Unit. The facility does have an active Resident Council.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERRILL GARDENS AT WEST COVINA	FACILITY NUMBER: 198603348
	VISIT DATE: 10/06/2023

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

8. Food Service: Currently the facility has no resident is on a modified diet. The facility has sufficient 2 days perishable and 7 days non-perishable food supply and emergency food supply stored and locked in the quiet room in the memory care unit. Sanitation practices and kitchen cleanliness was observed.

9. Incidental Medical and Dental: LPA inspected six (6) residents' medication which include (2) from Assisted Living and four (4) from Memory Care Unit and they are centrally stored and locked in the medication room and they are seemed accurate and updated and also contained 30 days supply of medication. The facility would also provide medical and dental transportation if needed.

Due to time restraints, LPA was not able to complete all the domains today, LPA will come back another time to review which include Personnel Records-Training, Disaster Preparedness and Residents with Special Health Needs.

No deficiencies were observed on today's visit.

Exit Interview Conducted and A copy of the report was provided to Monica Chavez.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3