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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200597
Report Date: 06/05/2023
Date Signed: 06/05/2023 02:47:34 PM

Unfounded


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
05/31/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230531094544
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: 94DATE:
06/05/2023
UNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Jillian Hunter, General Manager TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Yelled at and verbally threatened by co-worker in front of residents at the facility
INVESTIGATION FINDINGS:
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On 06/05/2023 at approximately 12:39 pm Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct complaint investigation for the above allegation. LPA met with General Manager, Jillian Hunter and explained the purpose of the visit.

During the course of the investigation, LPA interviewed 6 Staff and 3 residents and collected the staff schedule and video surveillance footage of the altercation. Based on interviews it was evident that there was a verbal altercation that occurred between two staff on 05/21/23. All the staff interviews stated that the event occurred in the kitchen then moved outside. All staff stated that there were no residents present during the incident, and all of the residents interviewed stated they were not aware of an incident occurring between staff on that date.

Continued on 9099-C....

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
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 2
Control Number 15-AS-20230531094544
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: 06/05/2023
NARRATIVE
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...Continued from 9099
We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted with General Manager and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2