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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200879
Report Date: 08/10/2022
Date Signed: 08/10/2022 04:31:33 PM

Document Has Been Signed on 08/10/2022 04:31 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:DILLON R. CAGULADAFACILITY TYPE:
740
ADDRESS:5238 CORONADO AVETELEPHONE:
(510) 338-4543
CITY:OAKLANDSTATE: CAZIP CODE:
94618
CAPACITY: 150CENSUS: DATE:
08/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:David Tamo, General ManagerTIME COMPLETED:
04:45 PM
NARRATIVE
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On 08/10/22 at 1:25PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving self-reported incident dated 08/02/2022 submitted to CCLD regarding medication error. LPA explained the purpose of the visit with general manager.

Based on the record review and interviewed, LPA observed that resident R1 was given wrong medication Levothyroxine 100mg x1 tablet which belonged to resident R2. LPA spoke with R1, R1 stated that she didn't feel sick, however, staff still wanted her to be checked by doctor so 911 call was activated. R1's son-in-law arrived at facility before ambulance came then took R1 to hospital. LPA observed that the hospital discharge paper indicated "Hypotension due to drugs". Resident stated that she has not been having symptoms due to wrong medication since then. Due to no injury or medical issue was resulted to R1 as of today, no civil penalty is assessed.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809-D. Failure to submit proofs of correction (POC) by plan of correction due date and/or any repeat deficiency within a 12-month period may result in civil penalties.

Exit interview conducted with general manager, appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/10/2022 04:31 PM - It Cannot Be Edited


Created By: Catherine Lin On 08/10/2022 at 03:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MERRILL GARDENS AT ROCKRIDGE
FACILITY NUMBER: 019200879

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2022
Section Cited
CCR
87465(a)(5)(A)

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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,,,
(5) Facility staff, except those authorized by law...Assistance with self administered medications shall be limited to the following:
(A) Medications usually prescribed for self-administration which have been authorized by the person's physician.

This requirement is not met as evidenced by…
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General manager agreed to retrain staff on medication, and provide a detail planing how to prevent same incident happen in the future, and submit to CCL by the POC due date.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Wrong medication was given to R1 which poses an immediate 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 Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022


LIC809 (FAS) - (06/04)
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