Merrill Gardens at West Covina

Type of visit: Annual/Random

Licensing Program Analyst(LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Sherry Fischer, Administrator, who assisted with visit. LPA explained the reason for the visit. Facility is licensed to serve residents over 60 years old, and approved for Dementia Care. Approved for 150 non-ambulatory, of which 15 may be bedridden, approved in rooms in memory care unit. Hospice Waiver approved for 15 residents. There are a total of 111 apartments, 13 of those in memory care unit and 2 of those 13 apartments are shared. This is a 5-story building. 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. The hot water temperature was tested randomly chosen room / apartments and measured within Title 22 Regulation guidelines. 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. Smoke /carbon monoxide detectors were operable. Continue 809C 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 there is sufficient perishable and non-perishable food.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 7/20/26. LPA reviewed 7 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.the state’s words, verbatim · CDSS document, Aug 4, 2026

Allegation investigated: Staff did not assist resident off the floor when requested. Staff did not provide adequate supervision resulting in resident wandering into another resident's room.

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced complaint visit to address the allegations listed above. LPA Met with Sherry Fischer, administrator for the facility, and explained the purpose of the visit. The investigation consisted of the following: LPA obtained staff and resident rosters, interviewed Residents #1 - 11 (R1 - R11), Staff #1 - 3 (S1 - S3), obtained a copy of the report number from the West Covina Police Department, obtained the facility policy concerning Emergency Response Systems, and also obtained the Physician's Report for R1. Since the initial visit, LPA interviewed Staff #4 (S4). During today's visit, LPA is delivering the findings of the investigation. The investigation revealed the following: In regards to the allegation that "Staff did not assist resident off the floor," it is alleged that a S4 refused to assist R1 out of bed after they had fallen in their room and used their call button to request assistance, and was advised by S4 to call 911 instead. Unsubstantiated 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.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 28-AS-20260303152721

Type of visit: Case Management - Incident

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.the state’s words, verbatim · CDSS document, Oct 23, 2025

Type of visit: Required - 1 Year

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 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.the state’s words, verbatim · CDSS document, Sep 11, 2025

Type of visit: Required - 1 Year

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 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.the state’s words, verbatim · CDSS document, Sep 10, 2024

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, Dec 14, 2023

Allegation investigated: Questionable Death.

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 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.the state’s words, verbatim · CDSS document, Nov 9, 2023 · control 28-AS-20230711131239

Type of visit: Case Management - Annual Continuation

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.the state’s words, verbatim · CDSS document, Oct 13, 2023

Type of visit: Required - 1 Year

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) 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. 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.the state’s words, verbatim · CDSS document, Oct 6, 2023