Inspection Reports for Merrill Gardens at West Covina

A case management visit was conducted to obtain additional information regarding an incident report received on 10/21/2025 about a resident who committed suicide in their room on the same day.

The resident was found non-responsive by staff and emergency services were called. The police and fire departments responded and initiated an investigation. The Medical Examiner removed the body later that day. Documentation related to the resident and incident was reviewed during the visit.

An unannounced annual inspection visit was conducted to evaluate compliance with licensing requirements for the facility licensed as RCFE/Dementia for age 60 and over.

The facility was found to be in good condition with no deficiencies observed. Resident apartments, common areas, medication storage, fire safety equipment, and emergency preparedness were all compliant with regulations.

An unannounced annual inspection was conducted to evaluate compliance with licensing requirements for the Merrill Gardens at West Covina facility.

The facility was found to be clean, well-maintained, and in good repair with no deficiencies observed. Resident apartments, medication storage, kitchen, and safety equipment were inspected and found compliant with regulations.

Case management visit conducted as a follow-up to a possible concern about grab bars in the residents’ bathrooms.

All bathrooms inspected were equipped with grab bars that met ADA requirements. No deficiencies were observed during the visit.

The inspection was an Annual/Required visit conducted to complete evaluation of three domains: Personnel Records-Training, Disaster Preparedness, and Residents with Special Health Needs.

No deficiencies were observed during the visit. All staff files were complete with required documentation, the facility had an updated Emergency Disaster Plan and recent fire drill, and residents with special health needs were properly documented.

The inspection was an unannounced required 1-year visit to evaluate compliance with regulatory standards using the full Care Compliance and Regulatory Enforcement (CARE) Tools.

The facility was inspected across multiple domains including infection control, operational requirements, physical plant safety, staffing, resident records, residents' rights, planned activities, food service, and incidental medical and dental. No deficiencies were observed during this visit.

The inspection was an unannounced complaint investigation visit conducted to investigate an allegation that the facility failed to provide resident records as requested by the resident's legal representative.

The investigation found that the facility received a formal records request on September 6, 2023, but failed to provide the requested resident records by the due date of September 11, 2023. The allegation was substantiated based on interviews and record review, citing a violation of resident rights under Title 22, Division 6 Health and Safety Code.

The complaint alleged that the facility failed to provide resident records requested by the resident's legal representative via Federal Express on September 6, 2023. The facility did not provide the records by the required deadline of September 11, 2023. The allegation was substantiated.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-01-13 regarding allegations of maintenance delays, staff disrespect, and unmet resident needs at Merrill Gardens at West Covina.

The investigation found insufficient evidence to substantiate the allegations. Maintenance issues were addressed timely, staff were not found to be disrespectful, and resident needs, including those in the memory care unit, were met according to interviews and documentation.

The complaint included allegations that staff had not fixed residents' showers in a timely manner, spoke disrespectfully to residents, and did not meet residents' needs, particularly in the memory care unit. After interviews with residents, staff, and administrators, and review of records, the allegations were determined to be unsubstantiated due to lack of sufficient evidence.

An unannounced complaint investigation visit was conducted in response to allegations that facility staff were not allowing resident council meetings to be conducted in private and were racially altering the bylaws of the resident council.

The investigation found that staff attend resident council meetings only by invitation and have not attended meetings in the past year. Residents and staff denied the allegations of racial alteration of bylaws, with some residents noting limited facility involvement. There was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated finding.

The complaint investigation was unsubstantiated. Allegations included staff not allowing private resident council meetings and racially altering resident council bylaws. Interviews with staff, residents, and the General Manager did not provide sufficient evidence to prove the allegations.

Licensing Program Analyst Kimberly Ramirez conducted an unannounced required Annual Visit focusing on COVID-19 Infection Control Practices and overall facility compliance.

The facility was found to be in compliance with no deficiencies observed. Resident rooms were clean and properly furnished, water temperatures were within required ranges, safety equipment was present and functional, and food storage and safety protocols were properly maintained.

The visit was an unannounced complaint investigation conducted in response to an allegation that a resident was financially abusing another resident in care.

The investigation found no preponderance of evidence to prove the alleged financial abuse occurred, and the allegation was determined to be unsubstantiated.

The complaint alleged that a resident was financially abusing another resident. The investigation included review of physician reports, capability evaluations, staff and family interviews, and found no proof of financial abuse though there was suspicion of potential future abuse. The allegation was unsubstantiated.

An unannounced annual visit was conducted using the Infection Control Evaluation Tool to evaluate compliance with regulations and infection control standards.

The facility was toured and inspected including physical plant, medication records, and food supply. No deficiencies were observed during the visit. Safety equipment and resident accommodations met regulatory requirements.