079201165-1-18-2023-15-AS-KHOS-CRLRBT-20230507125316

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201165
Report Date: 01/18/2023
Date Signed: 01/18/2023 04:37:43 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
12/30/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20221230095451

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:	03:10 PM
MET WITH:	Lydia Hertzler, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility memory unit lacks adequate staffing to meet residents needs

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 deliver findings on the above allegation. LPAs explained the purpose of the visit with Administrator Lydia Hertzler and facility nurse Syritta Rogers.

Allegation: Insufficient staff to meet the needs of the residents

LPAs reviewed staff schedule for the facility, facility has Med Tech, support staff and other agency staffing available on schedule. Facility had sufficient staffing for all three (3) shifts. Residents were observed calm and comfortable in their surroundings. LPAs attempted to interview residents in care but due to residents’ diagnosis the resident were not able to answer LPAs interview questions.

...Continues 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-20221230095451

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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LPAs conducted interview with staff and based on the interview, on 12/26/2022, there was a staff who called in sick, the facility Administrator called staffing agency to help on the in-house staff, a universal worker was scheduled, facility nurse and MedTech helped the caregivers who was scheduled on that day. Staff interview revealed that there was no unusual incident report happened on that day and staff stated that there were enough workers on the floor to take care of the residents.

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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