Inspection Reports for
Merrill Gardens at Rolling Hills Estates

The complaint was substantiated based on interviews with seven staff members and one witness, review of Unusual Incident Reports, progress notes, and staff training records. The facility retrained staff and submitted a plan of correction.

The investigation substantiated the allegation that on 01/03/2026, Resident 1 received Resident 2's medication in error and Resident 2 did not receive their scheduled noon medication. Staff involved were retrained, and a plan of correction was developed.

The complaint alleged insufficient staffing (one caregiver per twenty residents), failure to meet residents' hygiene needs, and failure to meet residents' dental hygiene needs. All interviewed staff and residents denied these allegations. Record reviews supported compliance with staffing regulations and care plans. The allegations were determined to be unsubstantiated.

The investigation found no preponderance of evidence to substantiate the allegations regarding staffing sufficiency, resident hygiene, and dental hygiene needs. Interviews and record reviews indicated compliance with regulations and care plans. No deficiencies were cited during the visit.

The facility was found to be clean, sanitary, and appropriately furnished with no observed deficiencies. All safety equipment was operable, infection control practices were followed, and records were maintained in order. No citations were issued during this visit.

The Licensing Program Analyst observed two delayed egress exits in working order with an open-release time of around 20 seconds and confirmed that alarms notify staff appropriately. No deficiencies were cited during the visit.

The facility was found to be in good condition with no deficiencies noted. All resident rooms, safety equipment, infection control practices, and documentation were inspected and found to be in order.

The complaint alleged that staff does not serve food of good quality, specifically that the food always has the same taste. The allegation was unsubstantiated after investigation.

The investigation included interviews with residents and staff, review of menus and dietician reports, and record checks. Seven out of eleven residents disagreed with the allegation, and records showed appropriate dietician visits and food handling certifications. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged neglect/lack of supervision resulting in a resident sustaining a fracture. The investigation included interviews, medical record reviews, and observations. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The investigation revealed multiple unwitnessed falls by Resident #1, including an initial fall outside the facility resulting in a fracture. Despite the incidents, there was insufficient evidence to substantiate neglect or lack of supervision by the facility, and the allegation was found to be unsubstantiated.

The complaint included allegations that staff yelled at a resident, handled a resident roughly, did not respond timely to a resident's call for assistance, and failed to follow reporting requirements. After investigation, these allegations were found to be unsubstantiated based on interviews and record reviews.

The investigation found insufficient evidence to substantiate the allegations. Interviews with residents and staff, as well as document reviews, indicated that the allegations were unsubstantiated and no deficiencies were observed during the visit.

The facility was found to be sanitary, appropriately furnished, and compliant with safety and infection control standards. However, a deficiency was cited related to staff not documenting medication given to residents' family, posing a potential health and safety risk.

The complaint investigation addressed three allegations: 1) Facility staff did not properly transfer a resident causing a fall; 2) Facility staff did not respond to residents' call buttons in a timely manner; 3) Facility staff not maintaining residents' hygiene. All allegations were unsubstantiated based on interviews and record reviews.

The investigation included interviews with staff and residents, review of records, and facility tour. All allegations were found to be unsubstantiated due to insufficient evidence to prove violations. Staff were verified to be properly trained and residents expressed satisfaction with care.

Allegation: Staff are mismanaging resident medication. The complaint was investigated through interviews with staff and residents, and review of training and care manuals. The allegation was found unsubstantiated.

The investigation included interviews and record reviews which found that staff followed proper procedures for medication management, including documentation of refused or spilled medication. Residents and staff denied any mismanagement. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint was substantiated. The allegation was that staff were not providing adequate food service, specifically serving cold food. Interviews with staff and residents, record reviews, and observations were conducted. The heating lamp was found broken but repaired. Despite some residents reporting cold food, staff stated food was served warm and reheated if needed. The preponderance of evidence supported the allegation.

The investigation found that residents were often served cold food for all three daily meals, with about 90% of residents reporting cold meals. The heating lamp was broken but has since been repaired. Observations showed food being cooked at proper temperatures, but some residents still received cold food due to delays in eating. The allegation was substantiated.

The facility was attempting to reassess R#1's medication management, but the resident and family were initially uncooperative. The facility decided not to proceed with eviction after working with the resident and primary care provider to adjust medication causing side effects.

The complaint was substantiated. The allegation was that staff were not providing adequate food service, specifically that food was served cold. Interviews with residents and staff, observations, and document reviews supported the finding that food was often served cold.

The investigation found that residents reported food was cold about 90% of the time for all three meals, while staff stated food was served warm and reheated if needed. The heating lamp was broken but has since been repaired. The allegation was substantiated based on interviews, observations, and record reviews.

The complaint involved allegations that food was served cold, food was not prepared in a safe/healthful manner, and staff were not observing personal hygiene and food service sanitation practices. Interviews with seven staff and ten residents revealed mixed responses but no sufficient evidence to corroborate the allegations. The complaint was determined to be unsubstantiated.

The investigation included interviews with staff and residents and a tour of the facility. The allegations were found to be unsubstantiated due to insufficient evidence to prove the violations occurred.

The inspection found that the kitchen, located on two floors, had dirty appliances, walls, floors, and counters, which violated the California Code of Regulations requiring the facility to be clean, safe, sanitary, and in good repair.

The facility was found to be in good repair with no deficiencies observed. Infection control practices were adequate, including sanitizing stations, PPE availability, and vaccination status of residents and staff. No citations or technical advisories were issued.

The facility was found to be clean, well-maintained, and compliant with infection control protocols including screening, PPE supply, and sanitation. No deficiencies were observed during the visit.