198603348-9-18-2023-28-AS-WSHO-CWPV2M-20231017160324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603348
Report Date: 09/18/2023
Date Signed: 09/18/2023 12:37:01 PM

Substantiated

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
09/11/2023 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20230911162517

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:	09/18/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Business Office Director Patricia Colin		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility failed to provide resident records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nune Margaryan conducted an initial 10-Day complaint visit to investigate the above allegation. The purpose of the visit was discussed with Business Office Director Patricia Colin.

The investigation consisted of the following: LPA obtained copies of staff & resident rosters, interviewed Staff 1 (S1) and requested Resident 1 (R1) file. Resident (R1's) file was reviewed. The following documents were obtained pertaining to R1:Identification and Emergency Information/Face Sheet, Admission Agreement, Physician Report, Pre-Placement Appraisal Information, Advance Healthcare Directive, Consent for emergency medical treatment, Personal Rights.

See LIC 9099C for report continuation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

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 3

Control Number 28-AS-20230911162517

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: 09/18/2023

NARRATIVE

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Allegation: Facility failed to provide resident records: It is alleged that on Thursday, September 06, 2023, the facility received a formal records request via Federal Express to obtain a copy of resident (R1's) records. The request was made by the resident's legal representative. As of today September 18, 2023, the documents had not been provided. They were due Monday, September 11, 2023. Business Office Director confirmed the records request was received on late September 06, 2023. Business Office Director stated that documents were provided to Facility Legal Department on September 07, 2023 for review. Business Office Director stated that is the facility policy and usually they get back from them in a 24 hours. Copy of email was provided to LPA that shows email sent to Legal Department on 09/07/23 at 9:29 am. Business Office Director was not able to provide any confirmation that requested documents were sent to the resident's legal representative. Based on interviews and record review, the findings indicate that the facility did not provided the documents as of 09/18/23. Therefore, there is sufficient evidence to corroborate the allegation.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22, Division 6 Health and Safety Code, Chapter 3.2 Residential Care Facilities for the Elderly Article 02.5 Resident's Bill of Rights.
See LIC 9099D.

Exit interview was conducted with Business Office Director. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230911162517

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 09/25/2023 Section Cited HSC 1569.269(a)(21)	1 2 3 4 5 6 7	Enumerated rights; severability.Residents of residential care facilities for the elderly shall have all of the following rights:To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies.This requirement was not met evidenced by:	1 2 3 4 5 6 7	Business Office Director agreed to submit a written plan of correction addressing resident records, enumerated rights; severability, and facility procedures regarding resident records request. Submit by POC due date.
	8 9 10 11 12 13 14	Based on record review, the facility received a formal request on 09/06/ 2023 for records of R1 and failed to provide the records within 2 business days, as required per regulation; which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

LIC9099 (FAS) - (06/04)

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