Inspection Reports for Merrill Gardens at Rolling Hills Estates
627 Silver Spur Rd, Rolling Hills Estates, CA 90274, CA, 90274
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on October 22, 2025, which was clean and showed the facility to be sanitary and well-maintained. Earlier in 2023, the facility received a few citations related to food service quality, specifically residents being served cold meals due to a broken heating lamp, and a cleanliness issue in the kitchen area, both of which were addressed during subsequent investigations. Several complaint investigations involving allegations of neglect, medication mismanagement, and staff conduct were unsubstantiated. The facility showed improvement over time, with no deficiencies noted in the last two annual inspections and recent case management visits. No fines, enforcement actions, or severe deficiencies were listed in the available reports.
Deficiencies per Year
4
3
2
1
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 123
Capacity: 150
Deficiencies: 0
Oct 22, 2025
Visit Reason
The inspection was an unannounced annual required visit conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be clean, sanitary, and appropriately furnished with no observed deficiencies. All safety equipment was operable, food supplies were adequate, and records including medication administration and personnel files were maintained in order. No citations were issued during this visit.
Report Facts
Bedrooms inspected: 9
Bathrooms inspected: 9
Residents' service files reviewed: 5
Staff personnel files reviewed: 5
Medication Administration Records reviewed: 5
Fire/Disaster Drills date: Sep 26, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracey E Holder | Executive Director | Met with Licensing Program Analyst during inspection and received the Facility Evaluation Report |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the inspection visit |
| Eva M Alvarez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 105
Capacity: 150
Deficiencies: 0
May 14, 2025
Visit Reason
An unannounced case management visit was conducted to verify that the facility's delayed egress exits are back in working order.
Findings
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.
Report Facts
Delayed egress exits observed: 2
Open-release time (seconds): 20
Census: 105
Total capacity: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Amaya | Resident Care Director | Met with Licensing Program Analyst during inspection and involved in testing delayed egress exits |
Inspection Report
Annual Inspection
Census: 93
Capacity: 150
Deficiencies: 0
Sep 14, 2024
Visit Reason
An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements for the facility.
Findings
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.
Report Facts
Hospice residents: 9
Hospice capacity: 15
Resident bedrooms: 114
Resident bathrooms: 115
Public restrooms: 7
Parking spaces: 62
Water temperature range: 105.2-107.9
Facility temperature range: 72-74
Fire drill date: Aug 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracey E Holder | General Manager / Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Ernand Dabuet | Licensing Program Analyst | Conducted the inspection visit |
| Janae Hammond | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 150
Deficiencies: 0
Jun 1, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident sustained a fracture while in care.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 150
Census: 141
Dates of incidents: Multiple fall incidents documented between 04/25/2023 and 07/17/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Yvette Lem | Resident Care Director | Met with Licensing Program Analyst during the investigation and received the exit interview |
| Debbie Infield | Administrator | Facility Administrator mentioned as unavailable during initial visit |
| Jeremiah Randle | Licensing Program Analyst | Conducted a prior 24-hour visit related to the investigation |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 150
Deficiencies: 0
Feb 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including staff yelling at a resident, rough handling of a resident, delayed response to a resident's call for assistance, and failure to follow reporting requirements.
Findings
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.
Complaint Details
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.
Report Facts
Residents interviewed: 10
Staff interviewed: 10
Capacity: 150
Census: 114
Response time: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Casey Ferreras | Senior Caregiver | Met with during inspection and received copy of complaint report |
| Debbie Infield | Administrator | Facility administrator at time of investigation |
| Trace Mallaret | Administrator | Met with during investigation visit |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 150
Deficiencies: 0
Feb 7, 2024
Visit Reason
The visit was conducted as a Case Management follow-up on an incident report received by the department regarding an allegation of a resident being drugged and sexually assaulted by facility staff.
Findings
The Licensing Program Analyst did not observe any deficiencies during the investigation and therefore no citations were issued at this time.
Complaint Details
The complaint involved an allegation by resident (R#1) that they were drugged and sexually assaulted by facility staff (S#1). The investigation included review of records, hospital discharge papers, and interviews with the administrator, staff, and residents. The complaint was not substantiated as no deficiencies were found.
Report Facts
Census: 114
Total Capacity: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Mallaret | Administrator | Met with Licensing Program Analyst during the visit and involved in interviews |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the Case Management visit and investigation |
Inspection Report
Annual Inspection
Census: 111
Capacity: 150
Deficiencies: 1
Nov 11, 2023
Visit Reason
The inspection was an unannounced annual required visit conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations for the facility serving non-ambulatory elderly adults.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Staff did not comply with documenting medication given to resident's family, posing a potential health, safety, or personal rights risk. |
Report Facts
Rooms inspected: 11
Residents' service files reviewed: 6
Staff personnel files reviewed: 6
Medication Administration Records reviewed: 3
Fire/Disaster Drills last conducted: Oct 27, 2023
Annual fire clearance last performed: Nov 22, 2022
Plan of Correction Due Date: Nov 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Eva M Alvarez | Licensing Program Manager | Supervisor overseeing the inspection |
| Tracey Mallaret | Administrator | Met with Licensing Program Analyst during inspection |
| Tracey Holder | Administrator | Received exit interview and report copy |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 150
Deficiencies: 0
Oct 19, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-11-16 alleging that facility staff did not provide residents' current medical records to emergency personnel, did not report incidents accurately, and did not dispense medication as prescribed.
Findings
The investigation included interviews with staff and residents, review of records, and a facility tour. All three allegations were found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred. No deficiencies were cited.
Complaint Details
The complaint involved three allegations: 1) Facility staff did not provide residents current medical records to emergency personnel; 2) Facility staff did not report incident accurately; 3) Staff did not dispense medication as prescribed. All allegations were investigated through interviews and record reviews and were found unsubstantiated.
Report Facts
Facility capacity: 150
Census: 112
Staff interviewed: 5
Residents interviewed: 10
Residents confirming medication dispensed as prescribed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
| Tracey Mallaret | General Manager | Met with Licensing Program Analyst during investigation and received report copy |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 150
Deficiencies: 0
Oct 19, 2023
Visit Reason
The visit was an unannounced complaint investigation initiated to obtain additional information regarding allegations that facility staff did not properly transfer a resident causing a fall, did not respond to residents' call buttons in a timely manner, and did not maintain residents' hygiene.
Findings
The investigation included interviews with staff and residents, review of records, and observation. All allegations were found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred. No deficiencies were cited.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included improper resident transfer causing a fall, delayed response to call buttons, and failure to maintain residents' hygiene. Staff and residents denied the allegations, and records showed compliance with training and care plans.
Report Facts
Capacity: 150
Census: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Tracey Mallaret | General Manager | Met with Licensing Program Analyst during the investigation and received the report |
| Debbie Infield | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 150
Deficiencies: 0
Jul 14, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff were mismanaging resident medication.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 150
Census: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation |
| Yvette Lem | LVN - Director of Care Services | Interviewed during investigation |
| Debbie Infield | Administrator | Facility administrator named in report header |
| Janae Hammond | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 150
Deficiencies: 1
Apr 14, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not providing adequate food service, specifically that food was served cold to residents.
Findings
The investigation found that residents reported food was served cold about 90% of the time, while staff stated food was served warm and reheated if needed. The heating lamp was broken but has since been repaired. The preponderance of evidence supported the allegation that residents were served cold food for all three daily meals over the last few weeks, resulting in a substantiated finding and a citation for violation of dietary quality and quantity requirements.
Complaint Details
The complaint was substantiated. The allegation was that staff were not providing adequate food service, specifically serving cold food to residents. The investigation included interviews with staff and residents, kitchen inspection, and document review. The heating lamp was found broken but repaired during the investigation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87555(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. This was not met as evidenced by residents having been served cold food to eat for all 3 daily meals for the last few weeks. | Type B |
Report Facts
Census: 105
Total Capacity: 150
Deficiency Type Count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Tracey Holder | Executive Director | Participated in exit interview and complaint investigation |
Inspection Report
Census: 105
Capacity: 150
Deficiencies: 0
Mar 17, 2023
Visit Reason
An unannounced case management incident visit was conducted following a Serious Incident Report (SIR) regarding a resident (R#1) possibly facing eviction due to non-compliance with medication management.
Findings
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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Will Carter | Operations Specialist | Met with Licensing Program Analyst during the visit and involved in discussions regarding resident medication management. |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 150
Deficiencies: 1
Mar 17, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff were not providing adequate food service, specifically that food was served cold to residents.
Findings
The investigation found that residents frequently received cold food for all three meals a day, substantiating the complaint. The heating lamp was broken but has since been repaired. Interviews with staff and residents, kitchen tours, and record reviews supported the finding that the food was often served cold.
Complaint Details
The complaint was substantiated. The allegation was that staff were not providing adequate food service, specifically that food was served cold to residents. Interviews and observations confirmed the allegation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. This was not met as evidenced by residents having cold food for all three meals a day. | Type B |
Report Facts
Capacity: 150
Census: 105
Deficiency Type Count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Will Carter | Operations Specialist | Met with the Licensing Program Analyst during the exit interview |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 150
Deficiencies: 0
Feb 1, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-01-23 regarding food service and hygiene concerns at the facility.
Findings
The investigation included interviews with staff and residents and a tour of the facility. The allegations that food was served cold, food was not prepared safely, and staff were not observing proper hygiene and sanitation practices were found to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint included allegations that food was served cold, food was not prepared in a safe/healthful manner, and staff were not observing personal hygiene and food services sanitation practices to protect food from contamination. After interviews with seven staff and ten residents, the allegations were found unsubstantiated.
Report Facts
Staff interviewed: 7
Residents interviewed: 10
Allegations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Will Carter | Administrator | Met with during investigation and exit interview |
| Lourdes Montoya | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 106
Capacity: 150
Deficiencies: 1
Jan 30, 2023
Visit Reason
The visit was a case management - deficiency visit conducted to observe and address deficiencies during an unrelated complaint visit.
Findings
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.
Deficiencies (1)
| Description |
|---|
| The kitchen appliances, walls, floors, and counters on both floors are dirty, violating maintenance and operation standards. |
Report Facts
Deficiency Type: Type B deficiency cited related to maintenance and operation
Plan of Correction Due Date: POC due date is 02/13/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Will Carter | Administrator | Assisted with the visit and was present during the exit interview |
| Lourdes Montoya | Licensing Program Analyst | Conducted the case management - deficiency visit and observed the deficiency |
| Stephanie Cifuentes | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 105
Capacity: 150
Deficiencies: 0
Nov 14, 2022
Visit Reason
An unannounced annual required and infection control visit was conducted to evaluate the facility's compliance with regulations and infection control practices.
Findings
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.
Report Facts
Residents ambulatory: 75
Residents non-ambulatory: 30
Residents bedridden: 0
Bedrooms: 114
Bathrooms: 124
First aid kits: 1
Fire extinguishers: 15
Hot water temperature: 118.1
Resident files reviewed: 3
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Soto | Licensing Program Analyst | Conducted the inspection and infection control visit |
| Tracey Holder | General Manager | Met with Licensing Program Analyst during inspection and exit interview |
Inspection Report
Annual Inspection
Census: 81
Capacity: 150
Deficiencies: 0
Oct 25, 2021
Visit Reason
An unannounced annual required visit was conducted with a primary focus on infection control measures.
Findings
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.
Report Facts
Residents non-ambulatory: 13
Hospice residents: 1
Bedrooms: 114
Bathrooms: 115
Public bathrooms: 7
Water temperature: 118.4
PPE supply: 30
Fire inspection date: Jul 28, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Infield | Administrator | Met with Licensing Program Analyst during the inspection |
| Ulysses Coronel | Licensing Program Analyst | Conducted the inspection visit |
| Janae Hammond | Licensing Program Manager | Named in report header |
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