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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201165
Report Date: 01/23/2025
Date Signed: 01/23/2025 03:28:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
12/09/2024 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241209113103
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: 131DATE:
01/23/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lydia Hertzler, General ManagerTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff do not ensure that medication is inaccessible to others
INVESTIGATION FINDINGS:
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On 01/23/2025 at 10:00AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to deliver findings regarding the allegation above. LPA met with General Manager, Lydia Hertzler and explained the purpose of the visit.

During the course of investigation, LPA interviewed complainant, resident and staff/MedTech.

Allegation: Staff do not ensure that medication is inaccessible to others

Interview with complainant, resident and staff/Med Tech (MT) reveled MT did leave Prilosec (acid reflux) over the counter medication in R1’s room after assisting R1 with medication and checking R1's blood sugar levels. R1 and granddaughter brought the medication to the front desk upon granddaughter leaving the facility after visiting her grandmother.

Continue LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
12/09/2024 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241209113103

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: 131DATE:
01/23/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lydia Hertzler, General ManagerTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Resident was hospitalized as a result of food poisoning
Staff are not providing adequate food service
Licensee does not ensure the facility has a full time staff person responsible for food service
INVESTIGATION FINDINGS:
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On 01/23/2025 at 10:00AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct complaint investigation and deliver findings regarding the allegations above. LPA met with General Manager, Lydia Hertzler and explained the purpose of the visit.

During the visit, LPA interviewed complainant, residents and staff. LPA obtained and reviewed records such as staff schedule, (LIC 500), kitchen staff schedule, residents’ roster with contact numbers, resident (R1) after visit summary report, residents' council letter to residents from General Manager (GM), thanksgiving brunch flyer with menu and table menu with alternative food options for residents.

continue on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20241209113103
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MERRILL GARDENS AT BRENTWOOD
FACILITY NUMBER: 079201165
VISIT DATE: 01/23/2025
NARRATIVE
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Continue from LIC9099

Resident was hospitalized as a result of food poisoning.

Interview with staff and record review revealed R1 wasn’t hospitalized as a result of food poisoning, however, was hospitalized for other health conditions. No one at the facility was sick and reported food poisoning.

Staff are not providing adequate food service.

Interviews with other residents and review of menu revealed that residents are satisfied with quality and quantity of the food provided and have many options to select from.

Licensee does not ensure the facility has a full-time staff person responsible for food service

Interviews with staff and record review revealed staff stepped up to assist in kitchen when needed to assure all residents had meals.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and this report provided

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20241209113103
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MERRILL GARDENS AT BRENTWOOD
FACILITY NUMBER: 079201165
VISIT DATE: 01/23/2025
NARRATIVE
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continue from LIC9099

Based on LPA observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.


Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20241209113103
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MERRILL GARDENS AT BRENTWOOD
FACILITY NUMBER: 079201165
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2025
Section Cited
CCR
87465(h)(2)
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(h) The following requirements shall apply to medications which are centrally stored:
2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication
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General Manager will implement a written plan to prevent this from happening again and submit plan to CCLD by POC date.
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This requirement is not met as evidenced by:
Based on interviews conducted, The licensee did not comply with the section cited above in not having medication inaccessible to resident which poses an immediate health, safety or personal rights risk to persons in care.
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CCR
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5