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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200879
Report Date: 02/01/2023
Date Signed: 02/01/2023 11:40:22 AM

Document Has Been Signed on 02/01/2023 11:40 AM - 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:REDDY, ANNAFACILITY TYPE:
740
ADDRESS:5238 CORONADO AVETELEPHONE:
(510) 338-4543
CITY:OAKLANDSTATE: CAZIP CODE:
94618
CAPACITY: 150CENSUS: 126DATE:
02/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Anna Reddy, AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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On 2/1/23 at 10:20 am, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving self-reported incident dated 12/20/22 submitted to CCLD regarding resident was being physical abused. LPA explained the purpose of the visit with administrator (ADM).

ADM stated a neighbor recorded a video that the caregiver hit resident's lower body while providing care. ADM showed the video to LPA. A SOC341 was submitted to CCL and Ombudsman. The police was called and involved. The subject staff was removed from schedule immediately then terminated. ADM had trained all staff on 12/20/22. and provided training record to LPA during visit.

A deficiency was cited from the California Code of Regulations, indicated on LIC809D. Failure to correct deficiencies by POC date and/or any repeat deficiencies within a 12-month period may result in additional Civil Penalties.

Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/01/2023 11:40 AM - It Cannot Be Edited


Created By: Catherine Lin On 02/01/2023 at 11:21 AM
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: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2023
Section Cited
CCR
87413(a)(2)

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87413 Personnel - Operations
(a) In each facility:
(2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice.
This requirement is not met as evidenced by…
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Deficiency Cleared.

Administrator had trained all staff on 12/20/22 and provided training record to CCL during visit.
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Based on record review and interview, the licensee did not comply with the section cited above. The caregiver hit resident's lower body was witnessed by a neighbor and video recorded as evidence 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: 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


LIC809 (FAS) - (06/04)
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