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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201165
Report Date: 05/09/2024
Date Signed: 05/09/2024 06:28:47 PM


Document Has Been Signed on 05/09/2024 06:28 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: 130DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Carol Anthony Business Office DirectorTIME COMPLETED:
06:45 PM
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On 05/09/2024 at 2:05PM, Licensing Program Analysts (LPAs) T. Syess-Gibson and C. Fowler, arrived unannounced to continue the 1-Year Annual Required inspection visit. LPAs met with Business Office Director (BOD), Carol Anthony, and explained the purpose of the visit. Administrator certificate #6017917740 expires 08/25/2024. The facility’s fire clearance was 135 non-ambulatory and 15 bedridden residents. Facility has hospice waiver for 15 residents.

LPAs toured the facility with Administrator including but not limited to apartments, bathrooms, kitchen, common area, med tech room, and outside. LPAs toured apartments #106, #112 and #140. All outdoor and indoor passageways are kept free of obstruction. LPAs did not observe any bodies of water. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non slip shower mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 07/27/2023. First aid kit was observed to be complete. Fire drill was last conducted on 04/07/2024.

Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/09/2024
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Continued from LIC809.

LPAs reviewed ten (10) staff records, ten (10) resident record, and they were current and complete. LPAs also reviewed the vehicle maintenance log.

LPA requested the following documents to be submitted to CCLD by 05/16/2024.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· Liability Insurance

LPA observed no deficiencies during visit:


Exit interview conducted. A copy this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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