<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200879
Report Date: 08/29/2022
Date Signed: 08/29/2022 01:37:42 PM


Document Has Been Signed on 08/29/2022 01:37 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: 120DATE:
08/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Aubrey Goo, AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/29/22 at 11:30AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving two self-reported incidents submitted to CCLD. LPA met with Administrator (ADM) and explained the purpose of the visit.

The incident dated 8/18/22 regarding to R1's elopement, LPA observed that R1 has hired 24/7 private caregiver with her. ADM had educated the private caregiver must accompany with R1 at all time. ADM also discussed with R1's family member that R1 should be moved to memory care unit or moved out to other facility for proper care needs.

The incident dated 8/19/22 regarding to R2's body injury, LPA observed that facility has the same setup of a stackable washer and drier installed in a closing door closet in each apartment, the machine was observed heavy and steady but not attached to the wall . R2 stated that she lost balance while doing laundry that day, she grabbed the opening of washing machine on the top and both washer and drier fell forward, lucky R2's walker blocked the way in between so the machine didn't fell on R2's body directly. R2 pressed call button, staff went to her room immediately and assisted her in time manor. R2 got injuries on her head and index finger. LPA discussed with ADM that facility might consider to secure washer and drier from now on due to the population they serve.

No deficiency cited during visit. Exit interview conducted with ADM, and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
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 1