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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201165
Report Date: 06/10/2022
Date Signed: 06/10/2022 07:21:23 PM

Substantiated


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
06/06/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220606121156
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: 58DATE:
06/10/2022
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Lydia Hertzler, Administrator TIME COMPLETED:
04:55 PM
ALLEGATION(S):
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Medication(s) are not being administered to resident(s) according to physician's instructions.
Untrained staff
INVESTIGATION FINDINGS:
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On 06/10/2022 at 9:55AM, Licensing Program Analyst (LPA) L Ibo arrived unannounced to conduct a unannounced complaint visit and deliver the investigation finding. LPA explained the purpose of the visit with Administrator Lydia H.

Allegation: Medication(s) are not being administered to resident(s) according to physician's instructions.

Based on interviews and record reviews, S3 administered incorrect dosage of medication to R1 and did not follow doctor’s order. An incident report was submitted to CCL office regarding this case.

...Continued on LIC9099C...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
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 6
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
06/06/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220606121156

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: DATE:
06/10/2022
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Lydia Hertzler, Administrator TIME COMPLETED:
04:55 PM
ALLEGATION(S):
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9
Residents are not being provided activities while in care
Facility does not have enough staff to meet resident's needs.
INVESTIGATION FINDINGS:
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On 06/10/2022 at 9:55AM, Licensing Program Analyst (LPA) L Ibo arrived unannounced to conduct a unannounced complaint visit and deliver the investigation finding. LPA explained the purpose of the visit with Administrator Lydia H.

Allegation: Residents are not being provided activities while in care

Based on observation and records review, LPA observed activity calendar for memory care department. LPA also observed care staff providing activities with residents. One resident (R2) stated that he does puzzles and reading, and he likes it. LPA observed entertainment performance for the assisted living department.

…Continue on LIC9099C…
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20220606121156
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 BRENTWOOD
FACILITY NUMBER: 079201165
VISIT DATE: 06/10/2022
NARRATIVE
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Allegation: Facility does not have enough staff to meet resident's needs.

During the course of interview, Administrator stated that there were staff that walked out from their job, but facility immediately contacted staffing agency and called corporate department to help out with staffing. LPA observed staffing agency and corporate staff during the visit.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur.



Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20220606121156
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 BRENTWOOD
FACILITY NUMBER: 079201165
VISIT DATE: 06/10/2022
NARRATIVE
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Allegation: Untrained staff

During the course of interview, Administrator admitted that S4 is assisting residents on medications without proper training from the facility, based on records review there is no proof of medication training for S4.
Based on the Department’s investigation, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. Facility is being cited per California Code of Regulations, Title 22.

Deficiency and plan and proof of correction were discussed with Lydia Hertzler, Administrator.

Exit interview conducted A copy of this report and Appeal Rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20220606121156
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 BRENTWOOD
FACILITY NUMBER: 079201165
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2022
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care Services. Once ordered by the physician, nonprescription PRN medications shall be given in accordance with the physician’s directions.
This requirement is not met as evidenced by:
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Facility Adminsitrator agreed to conduct training on following doctor's order and submit staff sign-in sheet to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above , S3 gave wrong dosage of medication and not following doctor's orders which poses a potential health and safety risk to the residents in care.
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Type B
06/17/2022
Section Cited
CCR
87411(c)(3)(D)
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(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(3) The training shall include, but not be limited to, the following:
(D) Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4). Any on-the-job training provided for the requirements in Section 87411(d)(4) may also count towards the requirement in this subsection.
This requirement was not met as evidenced by:
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Administrator agreed to will retrain staff for all required sessions on the regulation and submit training agenda and staff sign-in sheet to CCL by the POC due day.
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Based on observation, interview and record review, licensee did not comply with the section cited above. LPAs observed no training has been provided to staff after incident occurred which poses an immediate health, safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6