198603348-11-9-2023-28-AS-TVAO-CXLNE2-20231115092312

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603348
Report Date: 11/09/2023
Date Signed: 11/09/2023 11:43:51 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
07/11/2023 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230711131239

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: 114	DATE:	11/09/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Sherry Fischer - Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Questionable Death.

INVESTIGATION FINDINGS:

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Licensing program Analyst (LPA) Mary Flores conducted an unannounced subsequent visit regarding the above allegation. LPA met with Sherry Fischer and explained the reason for the visit.

The investigation consisted of the following: On 7/12/23 LPA requested copies of staff/resident roster and conducted a health and safety check tour of the facility. LPA requested the following documents: Physician's reports, death reports, hospice documents, for resident #1-#7(R1-R7), and employment application for 3 staff that cover night shift. On 10/31/23 Administrator provided a copy of death certificate for R1. On 11/9/23 LPA Flores interviewed 1 staff over the phone, 5 staff at the facility, and delivered findings.

The investigation revealed the following: Regarding allegation: Questionable death. It is alleged, on 6/9/23 Resident #1(R1) passed away suddenly and was observed well the same day. Interviews conducted with staff revealed, although there may have been concerns about the death of the resident.
(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230711131239

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/09/2023

NARRATIVE

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It was determined that staff were aware that R1 was under hospice care and had shown a decline in condition which was conductive to R1’s death. Staff do not have concerns regarding staff that are providing care to the residents at the facility.

Documents reviewed revealed the following: Facility submitted a Death Report dated 6/16/23 to the department and notes that on 6/9/23 R1 passed away at 11:25pm of coronary artery disease (CAD). Death Certificate dated 7/3/23 notes health conditions as the cause of death. Facility’s Letter Head notes R1 entered hospice on 2/11/23. Per documents reviewed R1 was actively receiving hospice services. R1’s Physician’s Report dated 2/11/23 notes, “no treatment needed for CAD as R1 is on hospice”. Outside Provider Notes - noted by hospice Skilled Nurse dated 5/31/23, 6/2/23, 6/7/23, and 6/9/23 note R1’s change in condition and show R1’s health declining. Deaths occurred at the facility between 4/26/23 to 7/1/23 were notified to the department via death reports. 6 out of the 8 deaths were of residents under hospice care due to a terminal illness or heart disease. The other 2 deaths recorder residents had a sudden change in condition and were send out to the hospital upon observing the change in condition. Per death reports both residents passed away at the hospital. Although R1 seem to have been well before 10:00pm, the hospice documents reviewed show that R1 was declining, R1's death was determined to be due to health conditions and not to other reasons.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Sherry Fischer and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

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