019200879-5-31-2023-15-AS-LHOS-CSCRRY-20230531131556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200879
Report Date: 05/31/2023
Date Signed: 05/31/2023 01:17:35 PM

Document Has Been Signed on 05/31/2023 01:17 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 ROCKRIDGE		FACILITY NUMBER:	019200879
ADMINISTRATOR:	REDDY, ANNA		FACILITY TYPE:	740
ADDRESS:	5238 CORONADO AVE		TELEPHONE:	(510) 338-4543
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94618
CAPACITY:	150	CENSUS: 120	DATE:	05/31/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Anna Reddy, General Manager		TIME COMPLETED:	01:30 PM

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On 05/31/23 at 11:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management inspection. LPA met with Abby Reddy, General Manager (S1) and explained the purpose of the visit.

On 05/29/23 at approximately 05:27 PM, Community Care Licensing Department (CCLD) received an Unusual Incident Report (UIR)via fax from S1 regarding a fire that took place on 5/28/23 at the facility.

Around 11:30 AM, LPA conducted interviews, captured photos and toured the facility with S1. The UIR and S1 stated that the fire started in Resident’s #1 (R1) room (RM) 507 on 5/28/23. What appeared to be cat food, was left on R1’s stove top and R1 was unaware that the stove-top burner was on. The rooms are individual apartments and multiple rooms had damage. R1 has relocated to 222, R2 was in RM 407 and has relocated to RM 310, R3 was in RM 307 and has relocated to RM 302, R4 remains in RM 207 where there appeared to be minimal water damage except in the bathroom where there is vertical perforations along the middle of the wall that’s located near the washer and dryer; the dimensions appear to be about 2 feet long and 3 inches wide. RM 507 appears to have fire damage to the stove, walls, and refrigerator. The entire apartment has a strong smell of smoke. Per S1, RM 407 has the most water damage since it is located directly under RM 507. At first glance, RM 307 appears to not have much damage, but there is a strong damp smell throughout the apartment.

...continued on LIC809C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ROCKRIDGE	FACILITY NUMBER: 019200879
	VISIT DATE: 05/31/2023

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...continued from LIC809

S1 has been in contact with a water restoration company, fans are placed throughout the facility and rooms on the 1^st, 2^nd, 3^rd, 4^th and 5^th floors. W1 stated that he/she cleaned about an inch and a half of excess water that was in the bathroom and has placed additional humidifiers in the apartment; S1 will assess if additional fans are needed for RM 207. R4 receives oxygen and hospice services. Being that the incident occurred over the Memorial holiday weekend, S1 and residents remain in contact with their insurance companies to investigate their personal and property damages. LPA requested documentation from insurance and/or water restoration company when they become available. LPA requested Resident’s (R1. R2, R3, R4) Identification/Emergency contact sheets be submitted to CCLD by 06/02/23. Fire Safety Training was performed with the Staff on 05/25/23 and one will be conducted with residents on 06/01/23.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

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