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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603348
Report Date: 10/13/2023
Date Signed: 10/13/2023 02:17:14 PM


Document Has Been Signed on 10/13/2023 02:17 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 COVINAFACILITY NUMBER:
198603348
ADMINISTRATOR:FISCHER, SHERRYFACILITY TYPE:
740
ADDRESS:1400 WEST COVINA PKWYTELEPHONE:
(626) 587-4318
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY:150CENSUS: 104DATE:
10/13/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Monica Chavez TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an Annual/Required visit by using the Compliance And Regulatory Enforcement (CARE) Tools on 10/6/2023 but due to time restrains and LPA Christine Wong has returned on today's date 10/13/23 to finish the remaining three (3) domains. LPA met with Receptionist Elizabeth Hernandez who allowed entry into the facility and Shortly after, the Administrator Sherry Fischer and Resident Care Director Monica Chavez arrived and assisted with the visit

On today's date, LPA inspected the three (3) domains include: Personnel Records-Training, Disaster Preparedness and Residents with Special Health Needs.

1. Personnel Records-Training: All the staff in the facility are over 18 years old, associated and fingerprint cleared with the facility. The administrator is Sherry Fischer and her administrator certificate expiration date was 3/12/23 but LPA reviewed the CCL website and its pending in our internal system. LPA reviewed all the staff files and they all have the required documents in file which included: health screening, TB test result, required training hours and updated first aid certificate

2. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610E) and its updated on 6/6/23. The last fire drill was conducted on 8/29/23. The facility has two temporary alternative shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training.

3. Residents with Special Health Needs: No residents in the facility with prohibited health condition. Currently there's one resident on hospice and three residents on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice.

No deficiencies were observed during the visit.

Exit Interview was conducted and a copy of the report was provided to Administrator Sherry Fischer.


SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
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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