019200879-2-1-2023-15-AS-KHOS-CPASXH-20230222131558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200879
Report Date: 02/01/2023
Date Signed: 02/01/2023 10:16:45 AM

Unsubstantiated

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
09/27/2021 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210927154001

FACILITY NAME:	MERRILL GARDENS AT ROCKRIDGE		FACILITY NUMBER:	019200879
ADMINISTRATOR:	CANDICE MOSES		FACILITY TYPE:	740
ADDRESS:	5238 CORONADO AVE		TELEPHONE:	(510) 338-4543
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94618
CAPACITY:	150	CENSUS: 126	DATE:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Anna Reddy, Administrator		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff are not answering call buttons timely
Staff are not meeting residents needs
Staff are not providing the quantity of food to meet residents needs

INVESTIGATION FINDINGS:

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On 2/1/23 at 9:20am, Licensing Program Analyst (LPA) C. Lin arrived unannounced to deliver findings on the above allegations and met with Administrator Anna Reddy. LPA explained the purpose of the visit.

On 10/05/2021, LPA Leslie Ibo initiated 10-day initial visit and obtained resident records.

On 01/19/2023, LPA L. Fontanilla obtained additional records including but not limited to Resident 1 (R1) Physician’s Report, hospice notes, pendant call logs for September 2021, staff roster, Admission Agreement and Needs and Services Plan and conducted interviews.

Conitnue LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 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)

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Control Number 15-AS-20210927154001

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 are not answering call buttons timely

LPA L. Fontanilla interviewed 4 out of 7 caregivers on January 19 and 20, 2023. Staff interviewed state that each time a staff responds to R1’s pendant call, R1 would not let the staff leave the room to attend to other residents until R1 is finished. Staff state that R1 would use the toilet from 45 minutes to an hour. And during those times, staff stayed with R1 and never left the room. In cases wherein the staff gets a call from other residents, staff would ask another caregiver to attend to the other residents.
On January 20, 2023, LPA L. Fontanilla reviewed pendant call log. Based on the log, R1 pressed pendant 4x on 9/26/2021 as follows:
Initiation Date Time Response Date Time Response Time
9/26/2021 8:42:18AM 9/26/2021 8:47:51 5 m
9/26/2021 10:02:00AM 9/26/2021 10:07:05 5 m
9/26/2021 1:12:42PM 9/26/2021 1:24:00 12 m
9/26/2021 3:03:35PM 9/26/2021 3:06:11 3 m
Caregivers interviewed state that average response time to pendant calls is 10 minutes.

Allegation: Staff are not meeting residents needs

On January 19 and 20, 2023, LPA L. Fontanilla interviewed 4 out of 7 caregivers. Staff interviewed state they are aware of R1’s needs as indicated in the Needs and Services Plan. And that all the care indicated in the care plan were provided to R1.
Caregivers interviewed state there were times R1 would ask staff to do tasks which are not indicated in the care plan. Staff would explain to R1 the reason why staff cannot do the tasks for R1.
All staff interviewed state that R1 was alert, able to communicate and did not have Dementia diagnosis Staff added R1 would complain if the caregivers do not attend to meet the needs of R1.

Continue on LIC9099-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 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 3

Control Number 15-AS-20210927154001

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 are not providing the quantity of food to meet residents needs

Based on interview conducted by LPA L. Fontanilla with 4 out of 7 caregivers, R1 was alert and did not have Dementia diagnosis. Caregivers provided R1 with the menu. R1 would call Front Desk to place order for food. Caregiver will pick up food from the kitchen and deliver to R1’s room. Caregivers interviewed state that R1 never complained about the quantity of food served. A review of hospice notes indicate that R1 was diagnosed with “Dysphagia, worsening with patient generally eating 3 small to medium sized meals 3x daily that take more than 60 minutes to eat. Patient sometimes fatigues before finishing or misses meals with appetite….”

Based on interviews and records reviewed, the above allegations are unsubstantiated.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

There is no deficiency noted.

Exit interview was conducted with XXX and a copy of this report was provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 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)

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