079200597-11-14-2024-15-AS-YFLS-DDJVKR-20250203153047

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200597
Report Date: 11/14/2024
Date Signed: 11/14/2024 01:26:06 PM

Unsubstantiated

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
05/30/2024 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20240530105952

FACILITY NAME:	MERRILL GARDENS AT LAFAYETTE		FACILITY NUMBER:	079200597
ADMINISTRATOR:	HUNTER, JILLIAN L		FACILITY TYPE:	740
ADDRESS:	1010 2ND ST		TELEPHONE:	(925) 299-6912
CITY:	LAFAYETTE	STATE: CA	ZIP CODE:	94549
CAPACITY:	100	CENSUS: 90	DATE:	11/14/2024
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Troy Beaton, Resident Care Director		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff did not seek medical attention for resident in a timely manner resulting in injuries.
Staff unlawfully evicted resident.

INVESTIGATION FINDINGS:

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On 11/14/2024 at 12:10 p.m., Licensing Program Analysts (LPAs) Greg Clark and David Doidge arrived unannounced to deliver findings in regard to the allegations above. LPA met with Troy Beaton, Resident Care Directorand explained the purpose of the visit.

During the course of the investigation the department interviewed the Reporting Party (RP), W1, 5 facility staff and 3 residents. The department also obtained R1’s medical records from John Muir Health.

R1 moved into the facility in May 2021 and lived there for a period of approximately two and half years. R1 lived in the independent living unit at the facility and as such did not require any staff assistance with his activities of daily living, he was completely independent.

Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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-20240530105952

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: 11/14/2024

NARRATIVE

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Continued from 9099

On the night of 11/14/23 S2 responded to a pull cord alarm from R1's living unit. When S2 arrived, she found R1 sitting in a chair at his desk with his legs crossed, not showing any signs of confusion or dizziness. S2 asked R1 if everything was aright and R1 replied “I’m okay.” R1 then told S2 that he fell. S2 called for the med tech. S3, the med tech arrived and checked R1 and found no signs of injury. S3 asked R1 if he bumped his head and needed 911 assistance. R1 said he did not hit his head and only fell to the floor. At least three times S3 asked R1 if he wanted them to call 911, but he declined every offer, stating he was okay. R1 then requested Tylenol from his cabinet for pain he was feeling in his back. R1 is diagnosed with chronic back pain.

On the morning of 11/15/2023, W1 received a phone call from R1. R1 directed W1 to go see him and when W1 arrived at the facility, R1 was pale and in pain. R1 was unable to move. W1 went downstairs and directed facility staff to call 911.

R1 was taken to John Muir Health Walnut Creek and diagnosed with acute right posterolateral eight, ninth, tenth and eleventh rib fractures, trace right and small left pleural effusions and hemoperitoneum; intraperitoneal and retroperitoneal hemorrhage identified. R1 was discharged from John Muir (date unknown) to a SNF for rehabilitation. R1 did not return to the facility.

R1 was interviewed at his current Assisted Living community. R1 was asked if he could explain what happened to him while he lived at Merrill Gardens that resulted in his hospitalization and R1 replied, “I can’t say. I was unconscious.” According to witnesses R1 never lost conscious. R1 only knows about what occurred between the night of 11/14/2023 and the morning of 11/15/2023 from what “people told me.” W1 provided R1 the details of the fall. W1 gathered information about the fall incident by talking with staff at the facility as he was not present during the incident. W1 stated that he was told R1 fell out of bed and was put back in bed by facility staff after he fell. R1 hit a corner wall and was knocked unconscious. R1 does not remember who found him, when he was found, or where he was found by facility staff and W1 did not provide further details. R1 was unable to provide a timeline of the events as a result of his injuries. R1 stated that he had no concerns regarding the care he was receiving at Merrill Gardens because he did not receive any care. R1 was an independent resident. If R1 required assistance from facility staff, he would push his pendant but never needed to while living at the facility.

Continued on 9099C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240530105952

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: 11/14/2024

NARRATIVE

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Continued from 9099C

Staff interviews that were conducted revealed that all staff were well trained in fall protocols of the facility. Since R1 lived in the independent unit NOC staff reported that they only check on those residents twice during their shift. Staff reported that they were trained to take the following steps in regard to a resident fall: non-witnessed falls require calling the Med Tech (MT). The assessment determines if the resident needs to be sent to the hospital. Independent living residents are alert and able to communicate coherently. If the resident declines an ambulance, as R1 did, staff respect the decision. On the night of the incident staff followed procedures, the MT (S2) was called and assessed R1. MT found R1 to be alert. The MT asked R1 if he wanted her to call an ambulance for him and he replied “No, I’m fine.”

Interviews with residents found that all the residents were happy living at the facility. R2 stating that she “feels safe” at the facility and describes the staff as friendly and helpful. R3 and R4 expressed similar feelings and thoughts.

On 11/14/2024, LPAs interviewed R1 at his new facility. LPAs also interviewed S4..

R1 stated that while at the SNF he was evaluated by S4. R1 further stated that S4 informed W1 that R1 would need a higher level of care if R1 returned to the facility resulting in a significant increase in cost. W1 and R1 interpreted this to mean paying more or seeking another facility. W1 consulted with R1 and they decided to seek another facility.

LPAs interviewed S4 who stated that he spoke with W1 about R1 needed a higher level of care, that results in higher cost. S4 further stated that he was concern about R1's safety if R1 did not have 1:1 supervision during waking hours. S4 provided W1 with a list of resources for private companions. S4 was unaware that R1 was not returning to facility until he saw W1 removing R1's private property form the facility.

The department has investigated the complaint alleging staff did not seek medical attention for resident in a timely manner resulting in injuries. LPAs investigated the complaint alleging staff unlawfully evicted R1. We have found that the complaints were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC9099 (FAS) - (06/04)

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