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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201165
Report Date: 05/03/2024
Date Signed: 05/03/2024 03:42:39 PM


Document Has Been Signed on 05/03/2024 03:42 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
OAKLAND ASC, 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: DATE:
05/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Lydia Hertzler, Executive DirectorTIME COMPLETED:
03:55 PM
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.On 05/03/2024 at 2:40PM, Licensing Program Analysts (LPAs) T. Syess-Gibson and L.Hall arrived unannounced to conduct a case management visit in regard to incident report received on 04/29/2024. LPAs met with Executive Director, Lydia Hertzler and informed him of the reason for the visit.

Based on the incident report received on 04/29/2024, Resident 1 (R1) returned to the facility with a new diagnosis that the facility hadn't been made aware of previously. S1 stated when R1 returned the discharge summary documents indicated the diagnosis. Facility staff requested a new physician's report to indicate diagnosis. Facility staff had conference call with family regarding continuing care of R1.

LPAs obtained the following documents: discharge summary notes from Kaiser hospital, physician report dated 6/14/2022 ,pre placement appraisal, and face sheet for R1.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
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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