079201165-5-16-2022-15-AS-LIBO-CEGW2C-20220516165408

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201165
Report Date: 05/16/2022
Date Signed: 05/16/2022 04:54:19 PM

Document Has Been Signed on 05/16/2022 04:54 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

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: 0	DATE:	05/16/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Jeri Shields, Vice President of operation & Lydia Hertzler, General Manager		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/16/2022, Licensing Program Analyst (LPA) Leslie Ibo arrived at the facility for the purpose of conducting an unannounced pre-licensing visit and met with Vice President of Operations (VPO) Jeri Shields and General Manager (GM) Lydia Hertzer. LPA observed zero resident during the inspection. LPA toured the facility inside and outside with GM and VPO. This residential care for the elderly facility (RCFE) consists of five (2) floors in one main building. The memory care unit (MC - referred to as the Garden House) located on the main floor was observed secure and locked with a delayed egress device with a security code to open the door. There is a secured and locked centralized storage area for resident medications. Centrally stored and locked medication rooms were observed equipped with medication carts and first aid kits including sterile dressings, bandages, thermometer, scissors, tweezers, and a first aid manual. The facility is clean and in good repair; inside temperature was comfortable at 75 degrees Fahrenheit (physical plant has centralized heating and cooling system in common areas and independent air units in each resident room); all window screens are clean and in good repair; there is appropriate and adequate lighting throughout the facility and in each room; assisted living rooms are equipped with, oven and washer and dryer in all the rooms; all indoor and outdoor passageways and stairways are free of obstruction; inclines, ramps, porches and potential hazard areas are well-lit and equipped with sturdy hand railings; physical plant is consistent with submitted facility sketch; disinfectants, cleaning solutions, poisons, and other items that could pose a danger are inaccessible - there are no firearms present; facility theft and loss program is posted; licensing complaint poster is posted;Covid19 posters are observed around the facility; resident personal rights posted; resident council rights posted. LPA observed there is covid19 screening station at the front desk. There is a signal system in all rooms - two were checked and were operational; there are no floor coverings that could pose a potential safety risk. LPA observed that there is a pool located at the facility courtyard, pool was observed to be locked. (Continued on 809C)

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/16/2022

NARRATIVE

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First floor has an activity center, computer room, beauty salon, theater, library, mailboxes for residents' mail, dining areas and several common sitting areas for residents and visitors to use. There are activity supplies and equipment, including daily newspapers and other reading materials; there are several activity spaces equipped for outdoor use; there are comfortable and appropriately furnished areas where friends and family can sit and talk. There are several fire extinguishers throughout the facility; there are laundry supplies and washer/dryer in each apartment; there are space for clean linen storage and a separate space for soiled linen; there is a designated laundry space located at the second floor of the building; there is an operating telephone available to the residents and staff. Emergency/Disaster Plan was observed complete and posted near a Land line phone.

The facility uses its own vehicles for transport of residents which are operational. Knives, matches, tools and other potentially dangerous items are inaccessible to persons in the memory care unit. Toxic substances are inaccessible; the large outdoor activity space on the first floor is enclosed with exits/entrances on non-memory care floors, wherein staff may accompany all residents if they wish to go outside; auditory devices are in place to monitor exits. Memory care or Garden house was observed to have enclosed outdoor activity. Emergency/Lift chairs were observed on the second floor stairs of the building

There is two-day supply of perishable and seven-day supply of non-perishable foods in stock; all foods were properly stored, containerized, labeled and within expiration; no spoilage observed; food supply represented all food groups; freezer temperature was -7 degrees F and the refrigerator temperature was 37 degrees F.

Pre-Licensing inspection was successfully passed. No deficiencies cited or observed during inspection. LPA advised VPO and GM that this report will be submitted to the Centralized Application Bureau (CAB) in Sacramento CA and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be needed.

Exit interview conducted & a copy of this report provided to VPO and GM.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

LIC809 (FAS) - (06/04)

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