079200597-9-30-2021-15-AS-YFLS-C7KMFB-20211007093405

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200597
Report Date: 09/30/2021
Date Signed: 09/30/2021 02:05:36 PM

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
09/24/2021 and conducted by Evaluator Allison O'Hollaren

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210924121446

FACILITY NAME:	MERRILL GARDENS AT LAFAYETTE		FACILITY NUMBER:	079200597
ADMINISTRATOR:	GOO, AUBREY		FACILITY TYPE:	740
ADDRESS:	1010 2ND ST		TELEPHONE:	(925) 299-6912
CITY:	LAFAYETTE	STATE: CA	ZIP CODE:	94549
CAPACITY:	100	CENSUS: 92	DATE:	09/30/2021
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Aubrey Goo		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not prevent resident from smoking

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 09/30/2021 at approximately 9:40am Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to conduct a 10-day initial complaint opening. LPA met with Administrator Aubrey Goo and explained the purpose of the visit.

During visit LPA interviewed Administrator, Resident Care Director, four staff, and eight residents. LPA reviewed resident roster, staff roster, admission agreement, physician reports, needs and services plan, email communications, and progress notes.

During the course of the investigation, it was revealed that for over three years staff and residents have informed managment of Resident R1 smoking on R1's balcony at the facility. The facility has a no-smoking policy which is included in the admission

Continued on LIC9099-C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'Hollaren	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

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 3

Control Number 15-AS-20210924121446

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 LAFAYETTE	FACILITY NUMBER: 079200597
	VISIT DATE: 09/30/2021

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
26
27
28
29
30
31
32

agreement that R1 signed during admission. The facility spoke to the authorized representatives of R1, but never issued a formal warning letter to R1 or R1's authorized representatives.

Based on LPA’s interviews and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

The following deficiency was observed (See LIC 809D) and cited from the California Code of Regulations, Title 22 and California health and safety code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'Hollaren	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20210924121446

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 LAFAYETTE	FACILITY NUMBER: 079200597
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/04/2021 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	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 and comfortable	1 2 3 4 5 6 7	By POC date Administrator agrees to send formal letter to R1, R1's authorized representative and CCLD outlining care plan for R1's smoking and warning for smoking in facility.
	8 9 10 11 12 13 14	accommodations, furnishings and equipment. Based on interview and record review the licensee did not comply with the section above. Management was informed of R1 smoking in the facility multiple times over three years and did not issue a formal warning letter to R1 or R1's authorized representatives which poses a potential health, safety or personal rights risks to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'Hollaren	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3