Merrill Gardens at West Covina.

During interviews with the residents, ten (10) out of eleven (11) did not corroborate the allegation. One of the residents interviewed stated that they have used their call pendant in the past, and that staff have always assisted them in a prompt manner whenever they have used it. Another resident interviewed stated that they have used the call button to request assistance from staff 2 - 3 times, and that each time staff responded within five (5) minutes and that staff have been helpful on each occasion. During interviews with the staff, none of them corroborated the allegation. During interview with S4, they explained that during the incident R1 had fallen off the side of their bed, and S4 stated that they proceeded with assisting R1 back into bed. S4 stated they initially asked R1 if they had hit their head or were injured and wanted to call 911, however R1 stated that they did not hit their head and did not wish to call 911. Another staff interviewed stated that the facility policy is to call 911 if a resident reports that they hit their head, however in this incident R1 did not hit their head and so paramedics were not called. In regards to the allegation that " Staff did not provide adequate supervision resulting in resident wandering into another resident's room," it is alleged that R11 had wandered into R1's bedroom during the night due to lack of supervision, and fell asleep on their couch, to which R1 requested assistance from staff members to assist R11 to their room. During interviews with the residents, ten (10) out of eleven (11) did not corroborate the allegation. During interview with R11, they stated that they do recall the incident. R11 stated that they recall that they were dizzy and half-asleep, missed the door to their bedroom and went into the wrong room on accident where they fell asleep on R1's couch. R2 - R10 did not report ever witnessing any residents wandering into the wrong bedroom in the past. During interviews with the staff, none of them corroborated the allegation. One of the staff interviewed stated that they were doing rounds to check on residents including R1 and R11, however during their previous check staff did not observe R11 in R1's room. Another staff member stated that after they became aware that R11 was asleep in R1's room, they assisted R11 back to their bedroom, and reiterated that staff do rounds during the night shift to supervise residents and ensure they do not wander into other resident bedrooms. 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.

Licensing Program Analyst (LPA) Nune Margaryan conducted a case management visit for the above facility to obtain additional information regarding an incident report received on 10/21/25 regarding Resident #1 who committed suicide on the same day in their room. Resident #1 resided in apartment 321. The resident was found by Physician’s assistant (PA) and Staff 1 (S1) on their bed non-responsive. 911 was called immediately. Family / POA was notified and arrived around 9:20 am. West Covina Fire Department (WCFD) responded and subsequently contacted West Covina Police Department (WCPD), who arrived and initiated an investigation. The apartment was secured. WCFD arrived at 9:00 am and WCPD arrived at 9:09 am. Case # 25-05708. Medical Examiner was called and arrived around 12:30 pm and body was removed, Case # 2025-16501. LPA requested and obtained the following documents: Residents and Staff roster, R1’s Identification and Emergency Information sheet, Admission Assessment, Physician’s Report, Medication list, Capability Evaluation - Results and Service Plan, Incident Report, Death Report, POA information. Exit interview was conducted and a copy of this report was given to Administrator.

Licensing Program Analyst(LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Sherry Fischer, Executive Director / Administrator, who assisted with visit. LPA explained the reason for 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. The facility is a 5 story building. There are a total of 111 apartments, 13 of those in memory care unit and 2 of those 13 apartments will be shared. On the first floor (AL Unit), it included Receptionist/Front Desk, Staff Offices, Theater room/Activity Room, Resident Mailbox area, Salon/Spa Room, Maintenance Office, Wellness Center, Dining area, Facility Kitchen, Public bathrooms for Male and Female, Staff Lounge and Private Dining Room. Memory Care Unit (Garden House) is a secured building. It includes 13 residents rooms, living room, laundry room, public bathroom, medication room and office. A random sample of apartments were inspected on each floor/unit. Each 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. Water temperature was measured in various different resident apartments throughout the facility and measured between 113.7F - 117.4F which falls within Title 22 Regulations. A locked storage area for centrally stored medications were observed in both medication rooms (AL Unit and Memory Care Unit). First aid kits were observed throughout the facility which included all required supplies. The walls, ceilings, floors, windows, and areas around the facility were clean and in good repair. Several fire extinguishers were observed throughout the facility. LPA also inspected the carbon monoxide detectors in the facility, and they are working properly. Continue 809C 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 Facility kitchen was inspected. All appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. Food supply adequate stored in the kitchen, storage room and consists of the following: 2 days perishable and 7 days non-perishable. Cleaning supplies and toxins were observed locked and inaccessible to residents. Doors, exits, hallways, and passageways were clear and free of obstruction. There are no pools or bodies of water in or around the facility. The outdoor patio areas were observed to have well shaded areas and were furnished for outdoor use. The last fire drill was conducted on 08/22/25. LPA reviewed 10 resident records to confirm emergency contact is updated, physician's reports are on file, and admission agreements are complete. 5 staff records were reviewed to confirm health screenings, training, and fingerprint clearances. LPA reviewed residents medications. Medications are documented properly and given as prescribed. No deficiencies were observed during today's visit. Exit interview conducted and a copy of the report was provided to Administrator.

Licensing Program Analysts (LPA) Nune Margaryan and Myra Cota conducted an unannounced annual visit using the Care Tool. LPAs met with Business Office Director Patricia Colin, who assisted with visit. LPAs explained the reason for 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. The facility is a 5 story building. There are a total of 111 apartments: 98 rooms in AL Unit and 13 in Memory Care Unit and 2 of the 13 apartments are shared rooms. On the first floor (AL Unit), it included Receptionist/Front Desk, Staff Offices, Theater room/Activity Room, Resident Mailbox area, Salon/Spa Room, Maintenance Office, Wellness Center, Dining area, Facility Kitchen, Public bathrooms for Male and Female, Staff Lounge and Private Dining Room. Memory Care Unit (Garden House) is a secured building. It includes 13 residents rooms, living room, laundry room, public bathroom, medication room and office. A random sample of apartments were inspected on each floor/unit. Each 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. Water temperature was measured in various different resident apartments throughout the facility and measured between 113.1F - 115.3F which falls within Title 22 Regulations. A locked storage area for centrally stored medications were observed in both medication rooms (AL Unit and Memory Care Unit). Several first aid kits were observed throughout the facility which included all required supplies. The walls, ceilings, floors, windows, and areas around the facility were clean and in good repair. Several fire extinguishers were observed throughout the facility. LPAs also inspected the carbon monoxide detectors in the facility, and they are working properly. Continue 809C 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 Facility kitchen was inspected. All appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. Food supply adequate stored in the kitchen, storage room and consists of the following: 2 days perishable and 7 days non-perishable. Cleaning supplies and toxins were observed locked and inaccessible to residents. Doors, exits, hallways, and passageways were clear and free of obstruction. There are no pools or bodies of water in or around the facility. The outdoor patio areas were observed to have well shaded areas and were furnished for outdoor use. The last fire drill was conducted on 8/15/24. LPAs reviewed 10 resident records to confirm emergency contact is updated, physician's reports are on file, and admission agreements are complete. 5 staff records were reviewed to confirm health screenings, training, and fingerprint clearances. LPAs reviewed 4 residents' medications. Medications are documented properly and given as prescribed. No deficiencies were observed during today's visit. Exit interview held. A copy of the report was provided to Business Office Director.

LPA Nune Margaryan conducted Case management visit for follow up possible concern about grab bars in the residents’ bathrooms. LPA met with Sherry Fischer and explained the purpose of the visit. At the time of visit LPA toured the facility and check the Grab Bars in the randomly selected rooms: #201, Room #206, Room #303, Room #315, Room #319. LPA observed that all the bathrooms are equipped with grab bars and measurements are in compliance under ADA requirements. No deficiencies observed. Exit interview conducted with Sherry Fischer and copy of the report is provided.

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.

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.

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) 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. 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.

During interviews with the Maintenance Director and the Administrator, it was shown in the facility's work order system that the most recent work order submitted for R1 and R2's room were from 3/7/2023, and therefore there was no work order submitted around the time that they requested their leaking shower head to get fixed. Additionally they explained that when a maintenance work order is received by them, it typically takes three (3) days to one (1) week to get fixed at the latest. R3 - R12 stated that they have never had any issues with maintenance when they have submitted work orders, and that their issues have been fixed in a timely manner. Five (5) out of (6) staff could not corroborate the allegation that it takes longer than one week at most to fix any type of maintenance issue in resident rooms. In regards to the allegation "Staff speak to residents disrespectfully", it is alleged that staff have spoken down to residents in a condescending and disrespectful manner before and has caused tension between the residents and the staff. During interviews with the Administrator, she explained that neither she nor any of the other staff members of the facility have treated the residents in a disrespectful manner. The administrator states that the facility always reminds staff of their obligation to provide 5-star customer service to the residents and provide training as well to ensure that all residents are treated with dignity and respect when working with residents. R3 - R12 all stated that they have never witnessed staff being rude or disrespectful to the residents in any way, and R6 stated that that the staff provide exemplary and wonderful service to all the residents that live in the facility. Five (5) out of six (6) Staff members could not corroborate the allegation that they have ever witnessed staff speaking to residents in a rude or condescending manner. In Regards to the allegation "Staff did not Meet Resident's Needs", it is alleged that staff have ignored the needs of residents and allowed them to wander, in particular R12 who lives in the memory care unit, and also because the grab bars that are installed in all of the resident's showers are inadequate and could potentially lead to a resident falling and thus leading to serious injury because the grab bars do not follow the American's with Disabilities Act (ADA) standards. Administrator explained that the needs of residents in the memory care unit are never ignored, and that she has conducted research with the facility's legal team who concluded the grab bars of the facility do meet the ADA standards. Interviews with R3 - R12 revealed that none of them had witnessed the needs of the memory care unit being ignored by the staff, and that they were all satisfied with the grab bars in their restroom, however R6 and R7 stated that they could foresee it being an issue with shorter residents. Five (5) out of six (6) staff members could not corroborate the allegation that the needs of memory care residents were not being met. 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 Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.

The investigation reveals the following: Regarding "Facility staff are not allowing resident council meetings to be conducted in private”. LPA interviewed the General Manager and confirmed facility staff attend resident council meetings by invitation only. The General Manager further stated the facility has not attended a resident council meeting in the last year. 2 out of 2 staff denied the allegation stating they are not allowed to attend the resident council meetings without an invitation. 8 out of 10 residents stated staff are not allowed to attend resident council meetings but has joined the meetings when invited. 1 out of 10 residents stated they believe another resident was sent to the meetings on behalf of the facility. 1 out of 10 residents stated they have seen the General Manager attend the resident council meetings in the past, but they are unsure if they were invited. The investigation reveals the following: Regarding " Facility staff are racially altering the bylaws of the resident council". it is alleged that the facility was able to radically alter the bylaws of the resident council. The General Manager denied the allegation, stating the first council president created he bylaws and the facility is not involved with the resident council bylaws. 2 out of 2 staff denied the allegation stating the facility is not involved with the bylaws of the resident council. 5 out of 10 residents stated the bylaws was created by the resident council without facility involvement. 3 out of 10 residents stated they have no knowledge of the facility altering the bylaws. 1 out of 10 residents stated some items was removed from the resident bylaws because it infringed upon the facility’s operational rights. 1 out of 10 residents stated they heard some sections of the resident council bylaws was overruled by facility general manager and was not added to the resident council bylaws. Based on LPA's interviews, 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 record provided.