079201165-10-28-2025-15-AS-HHUL-DN4VSP-20251104154153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201165
Report Date: 10/28/2025
Date Signed: 10/28/2025 03:58:49 PM

Unsubstantiated

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
07/17/2025 and conducted by Evaluator Tonica Syess-Gibson

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20250717102256

FACILITY NAME:	MERRILL GARDENS AT BRENTWOOD		FACILITY NUMBER:	079201165
ADMINISTRATOR:	SHIELDS, JERYL		FACILITY TYPE:	740
ADDRESS:	2600 BALFOUR RD		TELEPHONE:	(925) 297-6841
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	150	CENSUS: 115	DATE:	10/28/2025
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Lydia Hertzler, Executive Director		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff did not seek timely medical attention for resident after a change in condition
Staff do not ensure that resident call buttons are in proper working condition
Licensee did not abide by the terms and conditions of resident's admission agreement
Staff are not dispensing medications as prescribed

INVESTIGATION FINDINGS:

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On 10/28/2025 at 10:45AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a complaint investigation and deliver the findings in regard to the allegations above. LPA met with Lydia Hertzler, Executive Director, and informed her of the reason for visit.

During the investigation, LPA interviewed witness, staff members and obtained the following documents: staff roster, staff contact information, resident roster, R1’s admission agreement, preplacement appraisal, physicians report (LIC602), after visit summary, doctor notes dated April 08,2025, Medication Administration Record (MAR), unusual incident reports (LIC624), facility’s incident notes and facility’s pull cord log dated June 5, 2025

Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250717102256

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: 10/28/2025

NARRATIVE

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Continued from LIC9099

Staff did not seek timely medical attention for resident after a change in condition

During interviews and record review, it was revealed the facility contacted W1 to schedule a doctor appointment for R1, due to changes in condition observed observe by S2. Interviews revealed W1 stated she couldn’t schedule R1 an appointment due to R1 not having a doctor here in this area and the appointments were booked out for 6 months.

Staff do not ensure that resident call buttons are in proper working condition

During interviews, it was revealed that R1 pressed call button on June 5, 2025, and S3 responded timely. During interviews it was stated R1 pulled her pull cord and S3 arrived shortly and found R1 on the floor expressing suicidal intent. Record review revealed pull cord in R1’s bathroom was pulled at 5:16am and S3 arrived at 5:22am.

Licensee did not abide by the terms and conditions of resident's admission agreement

During interviews and record review, it was revealed that the facility did abide by the terms and conditions of R1’s admission agreement. Interviews revealed that the facility did abide by the terms of R1’s admission agreement, and that R1’s condition changes which resulted in a fee adjustment for R1’s care needs. Record review revealed, facility conducted another evaluation of the R1 and proposed an increase in fees to W1 due to an increase in care needs for R1

Continue on LIC9099C...

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250717102256

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: 10/28/2025

NARRATIVE

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Continued from LIC9099C

Staff are not dispensing medications as prescribed.

During interviews and record review, it was revealed that staff followed R1’s physician report regrading administering medications. Interviews revealed that S2 followed R1’s new Physician report (LIC602), dispensed the medications listed on LIC602 and informed W1 of the change in medications. Record review revealed that R1’s physician made adjustments to R1’s medications that was previously prescribed.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given to Lydia Hertzler.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025

LIC9099 (FAS) - (06/04)

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