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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200879
Report Date: 03/03/2022
Date Signed: 03/03/2022 03:01:25 PM


Document Has Been Signed on 03/03/2022 03:01 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:MERRILL GARDENS AT ROCKRIDGEFACILITY NUMBER:
019200879
ADMINISTRATOR:CANDICE MOSESFACILITY TYPE:
740
ADDRESS:5238 CORONADO AVETELEPHONE:
(510) 338-4543
CITY:OAKLANDSTATE: CAZIP CODE:
94618
CAPACITY:150CENSUS: 121DATE:
03/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Dillon Cagulada, AdministratorTIME COMPLETED:
03:15 PM
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On 3/3/2022 at 9:10am, Licensing Program Analyst (LPA) C. Lin conducted a Case Management visiting of health and safety check. LPA met with Administrator and explained the purpose of the visit.

LPA toured facility including but not limited to common area, dinning room, bedrooms, and bathrooms. and also interviewed residents and visitor. Based on the observation, record review, and interview, LPA observed food supplies was sufficient, daily menu was prepared weekly, and posted both in kitchen for staff and on dinning tables for residents. Dinning room opens from 7am to 7pm which was agreed upon on Admission Agreement.

Facility did adjust staff's schedule based on business needs, but the impact of Assisted living residents' needs and service was not observed. Staffing is adequate.

No deficiency cite during visit. Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
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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