079200597-1-26-2023-15-AS-KHOS-CP2QAN-20230214110014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200597
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:55:51 AM

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
05/11/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20210511102204

FACILITY NAME:	MERRILL GARDENS AT LAFAYETTE		FACILITY NUMBER:	079200597
ADMINISTRATOR:	GOO, AUBREY		FACILITY TYPE:	740
ADDRESS:	1010 2ND ST		TELEPHONE:	(925) 299-6912
CITY:	LAFAYETTE	STATE: CA	ZIP CODE:	94549
CAPACITY:	100	CENSUS: 90	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	William "Troy" Beaton, Resident care director (nurse)		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff are not available to meet resident needs

INVESTIGATION FINDINGS:

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On 01/26/2023 at 9:50AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegation above. LPA met with Resident Care Director, William “Troy” Beaton.

During the investigation, LPA toured the facility, reviewed documents such as but not limited to; Personnel report for 2021 and current report, Staffing schedule (2021), 2021 LIC9020A (register of facility residents) and current LIC9020A and R1’s chart. LPA attempted to interview R1, but she was not available during LPA visit. LPA conducted interview with facility residents.

…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: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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-20210511102204

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 LAFAYETTE	FACILITY NUMBER: 079200597
	VISIT DATE: 01/26/2023

NARRATIVE

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LPA reviewed staff schedule , facility has Med Tech, support staff available on schedule for Assisted living and memory care unit. Facility has sufficient staffing for all three (3) shifts. Residents were observed calm and comfortable in their surroundings. LPA conducted interview with residents and residents reported that they are happy living at the facility and had no issues around staff availability to meet their needs.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted Jilian Hunter, Executive Director and Troy Beaton, Resident care director. 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: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

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