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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200879
Report Date: 12/06/2022
Date Signed: 12/06/2022 03:42:59 PM


Document Has Been Signed on 12/06/2022 03:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:MERRILL GARDENS AT ROCKRIDGEFACILITY NUMBER:
019200879
ADMINISTRATOR:REDDY, ANNAFACILITY TYPE:
740
ADDRESS:5238 CORONADO AVETELEPHONE:
(510) 338-4543
CITY:OAKLANDSTATE: CAZIP CODE:
94618
CAPACITY:150CENSUS: 127DATE:
12/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Rob Arthur, Resident Care DirectorTIME COMPLETED:
03:50 PM
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On 12/6/22 at 12:45PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens (GLG) and check on residents, and a self-reporting incident regarding a resident's suicidal ideation. LPA met with Resident Care Director and explained the purpose of the visit.

During visit, LPA obtained GLG roster. A total of 12 residents from GLG are currently residing at MGR, 2 of them were new move-in since the last visit. LPA met with 2 residents who stated that they were safe comfortable living in facility.

Regarding the self-reporting incident, LPA obtained resident's physician's report and care plan for review. The resident is still hospitalized and has no definitive discharge date.

Exit interview conducted with Resident Care Director and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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