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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200879
Report Date: 07/11/2022
Date Signed: 07/11/2022 03:12:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/23/2021 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210223101041
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: 127DATE:
07/11/2022
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Lisa Read, Business Office DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident made to wait an excessive period of time for assistance on more than one occasion.
Resident's emergency call button malfunctioned.
INVESTIGATION FINDINGS:
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On 7/11/22, at 1:50pm, Licensing Program Analyst (LPA) C. Lin arrived unannounced to deliver findings on the above allegations. LPA met with Business Office Director, Lisa Read and explained the purpose of visit.

On 3/5/2021, LPA Allison O’Hollaren initiated initial 10-day investigation, obtained records and interviewed reporting Party (RP). On 10/14/2021, this complaint was reassigned to LPA Luisa Fontanilla.

LPA Fontanilla interviewed staff and reviewed the following records for Resident 1 (R1): call log, Physician’s Report, Service Plan and Monthly Task Log.

Based on the call logs reviewed for the period February 4 – 17, 2021, response time recorded ranges from 1 minute to 11 hours and 29 minutes.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
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 4
Control Number 15-AS-20210223101041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/11/2022
NARRATIVE
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Staff interviewed state that due to the pandemic, the facility was experiencing shortage of staff. The facility contracted with an agency for additional staff. However, since the agency staff are new and not familiar with the resident, it took longer for the agency staff to respond to the residents.
Staff interviewed confirmed with LPA that there were technical issues with the call button around the time the complaint was filed.
Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated.
California Code of Regulations, Title 22, are being cited on the attached LIC 9099D.

Exit interview was conducted with Business Office Director, Appeal Rights and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20210223101041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2022
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This requirement is not met as evidenced by:
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Administrator states staff training will be conducted about the facility’s protocol on pendant call response and submit proof of training to CCL by POC date,
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Based on interviews conducted and records reviewed, facility staff failed to respond to R1’s pendant call for assistance in a timely manner which poses a potential risk to the health and safety of resident under care.
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Type B
07/18/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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On 4/18/2022, LPA Fontanilla spoke with Dillon Cagulada, Manager who confirmed with LPA Fontanilla that the pendant call system had a lot of issues few months before he started working at the facility. Cagulada added that there were changes and upgrades done to the system and has been working fine.
By POC date, Manager will submit
1.self-certification stating the pendant call system has been fixed and currently functional
2.plan on how to address resident calls if pendant call system is broken
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Based on interviews conducted and records reviewed, the facility’s emergency call button had technical issues which poses a potential risk to the health and safety of clients under 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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/23/2021 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210223101041

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: 127DATE:
07/11/2022
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Lisa Read, Business Office DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility lacks sufficient staff to meet resident's needs.
INVESTIGATION FINDINGS:
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LPA Luisa Fontanilla interviewed Staff 2 (S2) and Staff 3 (S3). Staff interviewed confirmed with LPA that there was staff shortage during the pandemic. S2 and S3 state that the facility contracted with an agency for additional staff. And that there were 2-3 agency caregivers for each shift in addition to the regular facility staff.
LPA Fontanilla reviewed R1’s February Monthly Task Log and observed all activities of daily living (ADLs) listed were signed off.

Based on interviews conducted and records reviewed, the above allegation is unsubstantiated.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

There is no deficiency noted.

Exit interview was conducted with Business Office Director and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4