079201165-8-13-2024-15-AS-KHOS-D8HJTN-20240826072012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201165
Report Date: 08/13/2024
Date Signed: 08/13/2024 02:23:55 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
07/09/2024 and conducted by Evaluator Tonica Syess-Gibson

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240709100543

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: 118	DATE:	08/13/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Lydia Hertzler, General Manager/Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff does not ensure infection control guidelines are being followed
Staff do not ensure reporting requirements are being followed
Facility is in disrepair
Staff does not ensure facility temperatures are maintained between 78 - 85 degree
Licensee does not ensure staff are in good health to perform assigned tasks

INVESTIGATION FINDINGS:

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On 08/13/2024 at 11:30AM, Licensing Program Analysts (LPAs), T.Syess-Gibson and L.Fontanilla arrived unannounced to deliver complaint findings for the allegations above. LPAs met with Lydia Hertzler, General Manager/Administrator and explained the reason for the visit.

On 07/17/2024 LPA coducted a Ten (10) day visit. During the course of the investigation, LPA interviewed staff, observed , obtained and reviewed records.

Allegation: Staff does not ensure infection control guidelines are being followed
Based on interviews with staff, the facility followed infection control guidelines by isolating the covid positive residents in their apartments and provided Personal Protective Equipment (PPE) located outside of every apartment that was affected with COVID-19. The General Manager (GM) also provided weekly status letters of the outbreak to the community, keeping the community informed of the positive count which were posted on the bulletin board and left under the door of all residents. **Continue LIC9099C**

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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-20240709100543

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: 08/13/2024

NARRATIVE

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continue from LIC9099

Allegation: Staff do not ensure reporting requirements are being followed

Based on observation the GM followed reporting guideline by submitting Unusual Incident Reports (UIR) to CCLD within the time frame of outbreak. LPA received the following (UIRs) on July 5, 2024, July 7,2024 and July 11, 2024.

Allegation: Facility is in disrepair

Based on observation and interviews with staff, the kitchen area was affected by the Heating, Ventilation, and Air conditioning (HVAC) unit , however the residents weren’t affected. The residents still had air conditioning in the common areas such as dining room, activity room and their rooms, which causes no health concerns to the residents in care.

Allegation: staff does not ensure facility temperatures are maintained between 78 - 85 degrees

Based on observation and interviews with staff, the facility has had a problem with the Heating, Ventilation, and Air conditioning (HVAC) since 06/07/2024. One of the two units located outside of the facility controls the dining room, library, and the kitchen area, that’s the unit that has a down compressor. An attempt to fix the problem was made however, unsuccessful so the repair man did a temporary fix by re-wiring the unit which will allow the unit to work but not all thermostats can run same time. Which causes the kitchen area to be warmer than usual during (breakfast, lunch and dinner) times when the residents are in the dining room. The GM provided large industrial fans to provide relief to staff working in the kitchen. LPA observed three (3) fans located near the cooking area, prep station and the dishwashing station. The GM also allowed staff to take extra breaks if needed for relief throughout the day.

continue on LIC9099C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240709100543

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: 08/13/2024

NARRATIVE

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continued from LIC9099C

Allegation: Licensee does not ensure staff are in good health to perform assigned tasks

Based on interviews with staff a staff member reported to work as scheduled and wasn’t feeling well, decided to take a COVID-19 test and it was negative. The staff member waited approximately 30 minutes took another test and it was positive. The staff member immediately left the community. Once at home the staff member called the MedTech who was working closely with her that and encourage her to also test. The MedTech tested herself and tested positive at that tine she notified her manager and left the community. Neither employee returned to community, until they both tested negative which was on the Sixth day after testing positive.

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 this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

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