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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200597
Report Date: 05/21/2024
Date Signed: 05/21/2024 01:46:10 PM


Document Has Been Signed on 05/21/2024 01:46 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
CCLD Regional Office, 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:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Aubrey Goo, Interim AdministratorTIME COMPLETED:
02:00 PM
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On 5/21/24 at 10:15 AM, Licensing Program Analysts (LPAs) Greg Clark and A. Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Aubrey Goo, Interim Administrator and explained the purpose of the visit.

LPAs toured the facility including but not limited to 3 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 71 degrees F. The hot water temperature in a resident bathroom was measured at 115.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 9/14/23. Emergency Disaster Plan was last posted on 4/03/24. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 5/16/24.

LPAs reviewed 5 residents records and 5 staff records, and all were complete. LPAs also reviewed a sample of resident’s medications.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
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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