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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201165
Report Date: 10/12/2023
Date Signed: 10/12/2023 10:42:10 AM

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
07/31/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230731160712
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: 111DATE:
10/12/2023
UNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Lydia Hertzler, General Manager TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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On 10/12/2023 at 08:53 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver the findings for the above allegations. LPA meet with Lydia Hertzler, General Manager and explained the purpose of the visit. .

illegal eviction: The allegation refers to whether the licensee issued a verbal eviction notice to R1. During the investigation, LPA interviewed staff and residents. S1 stated that during an argument with R1, S1 stated “This is why we are looking into giving you 30 days to relocate”. This notice did not follow appropriate steps established by Law and was issued illegally. Therefore, the allegation that the facility issued an illegal eviction is substantiated.

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
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 4
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
07/31/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230731160712

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: 111DATE:
10/12/2023
UNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Lydia Hertzler, General Manager TIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
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3
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8
9
Food Quality
Facility not allowing large groups to dine together
Retaliation- for voicing their concerns
Staff had inappropriate interactions with residents in care
INVESTIGATION FINDINGS:
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On 1/4/2023 at 10:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver the findings for the above allegations. LPA meet with Lydia Hertzler, General Manager and explained the purpose of the visit. During the course of investigation, LPA obtained information, collected documents and interviewed staff and residents.

Food Quality: The allegation refers to whether there is enough good quality food at the facility. R1 stated that during a Mother’s Day event the facility had a special menu and when they went to order the prime rib the kitchen had ran out. S1 stated that because this was a special event, and they were having visitors dining with the residents there was a signup sheet to know how much the kitchen needed to order. The event had 32 additional people who attended this dinner than who did not signed up, and the kitchen was not prepared for this. The second event menu item was still available along with the regular menu items that were for everyone who chose not to participate in the event. Therefore, the allegation that the kitchen ran out of quality food is unsubstantiated.
Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20230731160712
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: 10/12/2023
NARRATIVE
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Facility not allowing large groups to dine together: The allegation refers to whether the licensee allowed large groups to dine together in the dining room. S1 stated that the facility at this time only has one table in the dining room that accommodates 6 or more people. S1 stated that they do not allow the residents to push together tables because it causes a safety hazard when too many walkers and wheelchairs are placed in one area close to the table and it prevents the serving staff from being able to do their job of delivering food to the table that is blocked. S1 stated that after residents expressed the want for lager tables, new tables have been ordered and are on their way. Therefore, the allegation that facility not allowing large groups to dine together is unsubstantiated.

Staff had inappropriate interaction with resident in care: The allegation refers to whether a staff member had inappropriate interaction with resident in care. R4 stated that while waiting for a ride in the front lobby S1 came over to talk with him about the funeral he was attending. S1 then sat on R4’s lap to hug him. In an interview with S1 that stated that they would never sit on a resident for many reasons including that it could hurt the resident and that it would be inappropriate to have that kind of interaction. Therefore, the allegation that staff had inappropriate interaction with a resident in care is unsubstantiated.

Retaliation: The allegation refers to whether the licensee retaliated against the resident by evicting them from the facility for voicing their opinion about the food to the other residents in the dining room. Based on interviews with staff and residents, the facility was already in the process for evicting the residents for other reasons when the situation in the dining room had occurred. Therefore, the allegation that facility not allowing large groups to dine together is unsubstantiated.


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

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

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20230731160712
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: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
10/26/2023
Section Cited
HSC
1569.683(a)
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a licensee of a residential care facility for the elderly who sends a notice of eviction ... in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons
This requirement is not met as evidence by:
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Administrator agreed to review the regulations regarding the eviction process and self certify knowledge of cited regulations, and submit copies to CCL by POC date.
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The facility staff telling the resident that they are getting evicted before the notice was given to the resident
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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: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4