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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200879
Report Date: 02/01/2023
Date Signed: 02/01/2023 04:01:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2023 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230124092737
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: 126DATE:
02/01/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Anna Reddy, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not administer medication as needed in a timely manner.
Staff didn't reappraise resident when resident health condition changed.
INVESTIGATION FINDINGS:
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On 2/1/2023 at 12:00PM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegations above, and deliver investigation findings. LPA met with Administrator and informed her the reason for the visit.

Allegation: Staff did not administer medication as needed in a timely manner - Substantiated
The Department has investigated this allegation and per records review and interviews, found that staff S3 has admitted not to administer medication to resident R1 a timely manner on 2/4/23. S3 stated that she was running around for other things until got a call from R1’s private caregiver, then S3 realized it was late. S3 went to R1’s room and gave medication to R1 afterwards.


Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20230124092737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 ROCKRIDGE
FACILITY NUMBER: 019200879
VISIT DATE: 02/01/2023
NARRATIVE
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Allegation: Staff didn't reappraise resident when resident health condition changed – Substantiated
The Department has investigated this allegation and per records review and interviews, found that staff did not update R1’s needs and services plan when R1 was admitted to hospice in May 2022. The previous needs & services plan was dated on 7/16/2018.

Based on information obtained, the preponderance of evidence is met, therefore the allegations are SUBSTANTIATED.

Deficiencies are cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of correction were discussed with Administrator. Exit interview conducted. Appeal Rights, LIC9099D, and copy this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230124092737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 ROCKRIDGE
FACILITY NUMBER: 019200879
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/08/2023
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility...
(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by…
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Deficiency Cleared,

Administrator had trained staff on medication on 1/31/23, no repeating training is needed within 24 hours..
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Based on observation the licensee did not comply with the section cited above. LPA observed staff didn't administer medication to resident timely poses an potential health, safety or personal rights risk to persons in care.
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Type B
02/08/2023
Section Cited
CCR
87463(a)
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87463 Reappraisals
(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary….
This requirement is not met as evidenced by…
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Deficiency Cleared.

No POC is needed as the deficiency was cited from previous complaint allegation in July 2022, and it was corrected. This alleged violation was for May 2022 which was before that. the new management team has updated residents' care plan up to day.
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Based on observation the licensee did not comply with the section cited above. LPA observed that staff didn't update care plan for resident who was admitted to hospice in May 2022 which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2023 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230124092737

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: 126DATE:
02/01/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Anna Reddy, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
Staff entering resident's room without consent. Staff did not accord privacy to resident.
Staff did not communicate with family member (POA).
INVESTIGATION FINDINGS:
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On 2/1/2023 at 12:00PM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegations above, and deliver investigation findings. LPA met with Administrator and informed her the reason for the visit.

Allegation: Staff entering resident's room without consent. Staff did not accord privacy to resident - Unsubstantiated
The Department has investigated this allegation and per observation and interviews, found that staff stated that they rang door belt before entering to residents’ apartments except having emergency situation. Five residents who were randomly interviewed stated that staff did ring door belt each time and residents felt enough privacy living in the facility.

Continue LIC9099A-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230124092737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 ROCKRIDGE
FACILITY NUMBER: 019200879
VISIT DATE: 02/01/2023
NARRATIVE
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Allegation: Staff did not communicate with family member (POA) – Unsubstantiated
The Department has investigated this allegation and per record reviews and interviews, found that a note indicated that staff did call resident’s POA on 1/2/23 then follow by an email on 1/3/23.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

No deficiency cited. Exit interview conducted with staff and a 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: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5