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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200597
Report Date: 08/29/2022
Date Signed: 08/29/2022 11:10:46 AM


Document Has Been Signed on 08/29/2022 11:10 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 LAFAYETTEFACILITY NUMBER:
079200597
ADMINISTRATOR:HUNTER, JILLIAN LFACILITY TYPE:
740
ADDRESS:1010 2ND STTELEPHONE:
(925) 299-6912
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:100CENSUS: 90DATE:
08/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:William Beaton (Troy), StaffTIME COMPLETED:
11:20 AM
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On 08/29/22 at 9:45AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving self-reported SOC341 dated 08/18/22 submitted to CCLD regarding staff member (S1) was in violation of HIPPA. LPA explained the purpose of the visit with staff, Administrator (ADM) Jillian Hunter arrived at a later time.

During the course of investigation, LPA observed that the incident had been reported to police department on 8/15/22. Police department involved and requested S1 to return properties including but not limited to laptop, keys, credit card, and photos to facility. S1 returned everything except photo albums to police department on 8/22/22. S1 told police officer that all paper photos had been threw away to a dumpster, police officer brought properties back to facility on 8/26/22.

In additional, ADM immediately took action of deactivating S1's key fobs, changing all access codes in facility for security purpose on 8/13/22, cancelled S1's company credit card on 8/15/22, and terminated S1 on 8/16/22. As of now, the incident has not resulted health and safety impacts to residents.

No deficiency 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)
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