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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200879
Report Date: 12/13/2022
Date Signed: 12/13/2022 03:13:42 PM

Substantiated


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
07/12/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220712070126
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: 128DATE:
12/13/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Anna Reddy, AdministratorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Facility did not follow COVID-19 protocols.
Facility did not have a current care plan for resident.
Facility did not have sufficient staff to meet residents' needs.
INVESTIGATION FINDINGS:
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On 12/13/2022 at 12:00 PM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct a subsequence complaint investigation visit in regard to the above allegations and delivered investigation findings. LPA met with Administrator and informed the reason for visit.

Allegation: Facility did not follow COVID-19 protocols – Substantiated
The Department has investigated this allegation and per records review and interviews found that staff S1, S2, S3, and S6 stated that facility didn’t designate staff to only take care of Covid-19 positive residents during Covid outbreak started in July 2022. Staff stated that the former resident care director S5 didn’t correct staff due to staff shortage in subject time period.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 15-AS-20220712070126
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: 12/13/2022
NARRATIVE
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Allegation: Facility did not have a current care plan for resident – Substantiated
The Department has investigated this allegation and per records review and interviews found that facility didn’t have current care plan for 3 residents who were randomly reviewed. The latest care plans for these 3 residents were observed dated in year 2019. Resident R1 has been requesting an updated care plan since the beginning of 2022, it has not been discussed and provided until the new management came on aboard in September 2022.

Allegation: Facility did not have sufficient staff to meet residents' needs – Substantiated
The Department has investigated this allegation and per records review and interviews found that only one care staff worked at PM shift 8 days in July staff work schedule, they were from 7/22/22 to 7/26/22, and from 7/29/22 to 7/31/22, and no care staff was scheduled to work at NOC shift on 7/31/22. Work schedule indicated that 2 care staff were scheduled at PM shift and 1 care staff was scheduled at NOC shift daily, however, staff was no show on above dates, facility was unable to provide information to proof additional care staff was added on schedule.

Based on information obtained, the preponderance of evidence is met, therefore the allegations are substantiated.

Deficiencies are cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of correction were discussed with the Administrator.

Exit interview conducted. Appeal Rights, LIC9099D, and copy this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20220712070126
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful...
This requirement is not met as evidenced by…
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Administrator agrees to retrain staff for infection control, and submit proof of training to CCL by POC due date.
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Based on observation the licensee did not comply with the section cited above. LPA observed staff crossover working between Covid-19 positive and negative residents which poses a potential health, safety or personal rights risk to persons in care.
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Type B
12/20/2022
Section Cited
CCR
87463(a)
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87463 Reappraisals
(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary….
This requirement is not met as evidenced by…
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Administrator agrees to review regulations, submit a self-certification to CCL by POC due date.
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Based on observation the licensee did not comply with the section cited above. LPA observed that care plan has not been updated for residents who change in health condition since 2019 which poses a potential 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20220712070126
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2022
Section Cited
CCR
87411(a)
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87411 Personnel Requirements-General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...facilities licensed for sixteen or more, sufficient support staff shall be employed…..
This requirement is not met as evidenced by…
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Administrator agrees to provide a planning of maintaining sufficient staff to meet residents' needs at facility, and submit to CCL by POC due date.
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Based on observation the licensee did not comply with the section cited above. Insufficient staff was observed on work schedule in July 2022 which poses a potential 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
07/12/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220712070126

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: 128DATE:
12/13/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Anna Reddy, AdministratorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
1
2
3
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5
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9
Resident had not received paid services (showers, status checks, etc.) according to contract.
Facility staff is not adequately trained.
Facility food is not adequate (lacks nutrition, freshness, unappetizing, poor quality, timeliness).
INVESTIGATION FINDINGS:
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Allegation: Resident had not received paid services (showers, status checks, etc.) according to contract – Unsubstantiated
The Department has investigated this allegation and per records review and interviews found that facility has shower schedules for residents. 7 residents were interviewed, 5 of them stated that their shower assistances were on schedule and needs were met in subject time period.

Allegation: Facility staff is not adequately trained – Unsubstantiated
The Department has investigated this allegation and per records review and interviews found that staff who were interviewed stated that they received adequate training regularly. R6’s individual training records was observed. 7 residents were interviewed, 5 of them stated that staff were trained and skillful.

Continue on LIC9099-A-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20220712070126
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: 12/13/2022
NARRATIVE
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Allegation: Facility food is not adequate (lacks nutrition, freshness, unappetizing, poor quality, timeliness) – Unsubstantiated
The Department has investigated this allegation and per records review and interviews found that facility menus were designed and monitored by Crandall Corporate Dietitians. Administrator stated that the corporation didn't allow facility to create separate menus. Administrator provided copies of dietitians quarterly audit report to CCL for review, it was the 4th quarter report of year 2022 dated on 11/8/2022. 7 residents were interviewed, 5 of them stated that food was adequate and service was met. Due to the communal dinning room was closed in Covid outbreak, meals were delivered to each resident's room. Some residents received meals later than normal meal time, residents stated that the delay was not bad and acceptable.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6