079201165-1-18-2023-15-AS-KHOS-CNLLL7-20230131075041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201165
Report Date: 01/18/2023
Date Signed: 01/18/2023 04:30:58 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/11/2023 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20230111144035

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: 104	DATE:	01/18/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Lydia Hertzler, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Authorized Representative is being charged extra fees.

INVESTIGATION FINDINGS:

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On 01/18/2023 at 10:15AM, Licensing Program Analysts (LPAs) L. Ibo and D. Fici arrived unannounced to conduct an unannounced complaint visit. LPAs explained the purpose of the visit with Administrator Lydia Hertzler and facility nurse Syritta Rogers.

Allegation: Authorized Representative is being charged extra fees.

During the course of investigation, LPAs conducted records review and interviews. LPAs gathered the following documents such as but not limited to physician’s report, invoices for R1, R2, & R3 from November 2022- January 2023, R1, R2 and R3’s care plans and R1, R2 & R3’s admission agreements.

Continue to LIC9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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-20230111144035

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/18/2023

NARRATIVE

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Records review revealed that there was no extra charge added to R1, R2 & R3’s invoices. LPAs conducted interview with F1, based on interview, facility staff informed F1 that R1 need one-on-one private caregiver and that will cost extra charge, however F1 stated that she has not received an invoice for the one-on-one care provided to R1.

LPA conducted interview with S1, based on interview with S1, she admitted that an extra fee was discussed with F1 to provide extra staff for R1, however since F1 did not agree with the extra charge the facility decided not to charge R1.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

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