079201165-4-4-2023-15-AS-KHOS-CQRNEN-20230410102412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201165
Report Date: 04/04/2023
Date Signed: 04/04/2023 05:21:11 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
03/29/2023 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20230329160121

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:	DATE:	04/04/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Lydia Hertzler, Administrator		TIME COMPLETED:	05:35 PM

ALLEGATION(S):

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Staff forced resident to shower
Staff increased level of care without resident's consent
Staff overcharged resident in care

INVESTIGATION FINDINGS:

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On 04/04/2023 at 1:30PM, Licensing Program Analysts (LPA) L. Ibo arrived unannounced to conduct an unannounced complaint visit. LPA met with Administrator Lydia Hertzler and explained the purpose of the visit.

Allegation: Staff forced resident to shower

Based on interview records review, R1 have a diagnosis of short bowel syndrome that causes the resident (R1) to have several bowel accidents. Based on interview with staff; the staff stated that they encourage R1 to take shower every time he had an accident, however the staff denied forcing R1 to take shower. The staff used stated they use change of face technique or have another staff talk with R1 the staff also use redirection technique. Residents was also interviewed and denied any staff forcing them to take shower.
...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: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

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-20230329160121

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: 04/04/2023

NARRATIVE

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Allegation: Staff increased level of care without resident's consent.

Based on interview and records review, R1 had a change of level of care due to change of behavior. S1 contacted R1’s representative to discuss about the new care plan. Records review revealed that R1’s care plan has an effective date of March 20,2023, however on March 18, 2023, R1 was moved out from the facility, due to the move out date, the care plan was not implemented.

Allegation: Staff overcharged resident in care.

Based on interview with staff and records review, R1 was not charge for the change of care plan since it was not implemented due to R1’s moving out from the facility before the effective date. Based on records review, the invoices have an consistent charges for the last three months and a prorate refund was also issued as soon as the resident (R1) moved out from the facility.

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: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC9099 (FAS) - (06/04)

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