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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201165
Report Date: 05/16/2022
Date Signed: 05/16/2022 04:55:25 PM


Document Has Been Signed on 05/16/2022 04:55 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 BRENTWOODFACILITY NUMBER:
079201165
ADMINISTRATOR:SHIELDS, JERYLFACILITY TYPE:
740
ADDRESS:2600 BALFOUR RDTELEPHONE:
(925) 297-6841
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:150CENSUS: 0DATE:
05/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jeri Shields, Vice President of operation & Lydia Hertzler, General ManagerTIME COMPLETED:
05:20 PM
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On 5/16/2022, Licensing Program Analyst (LPA) Leslie Ibo conducted an unannounced case management visit for a Component III presentation completed with Vice President of Operations (VPO) Jeri Shields and General Manager (GM) Lydia Hertzer.

LPA discussed commonly encountered problem areas in RCFE facility operations and gave VPO and GM sufficient information to operate the facility within substantial compliance.

LPA reviewed the following with GM during the Component III presentation:
· Operating Requirements
· Personal Rights of residents
· Physical Environment
· Personnel Requirements & Records
· Criminal Record Clearances, Associations & Civil Penalties
· Medical & Dental Care of residents
· Dementia Care
· Staff annual training requirements
· Covid19 information

Facility is ready to be licensed. No deficiencies cited or observed during this presentation.

LPA advised GM that this report will be submitted to the Centralized Application Bureau (CAB) in Sacramento CA and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be needed.

Exit interview conducted and a copy of this report provided to VPO & GM.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
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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