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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201165
Report Date: 06/10/2022
Date Signed: 06/10/2022 07:23:56 PM

Document Has Been Signed on 06/10/2022 07:23 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 BRENTWOODFACILITY NUMBER:
079201165
ADMINISTRATOR:SHIELDS, JERYLFACILITY TYPE:
740
ADDRESS:2600 BALFOUR RDTELEPHONE:
(925) 297-6841
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 150CENSUS: 58DATE:
06/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Lydia Hertzler, Administrator TIME COMPLETED:
07:45 PM
NARRATIVE
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On 6/10/2022 at 5:00 pm, Licensing Program Analyst (LPA) L Ibo arrived unannounced to conduct a case management visit. LPA was conducting interview and records review due to another visit. LPA found about elopement incident.

Based on records review, on 5/26/2022 R1 eloped from memory care department and was found at the parking lot by one of resident’s family member and redirect him back to the facility. CCLD office did not receive incident report and Administrator can’t provide proof of incident report submitted to CCLD office.

S2 is not associated at the facility, based on interview S2 started working on April 2022, this citation was corrected today, Business office Manager associated S2 on the facility.

The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted, Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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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Document Has Been Signed on 06/10/2022 07:23 PM - It Cannot Be Edited


Created By: Leslie Ibo On 06/10/2022 at 06:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MERRILL GARDENS AT BRENTWOOD
FACILITY NUMBER: 079201165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2022
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs.
-This requirement is not met as evidenced by:
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Administrator agreed to provide staff re-training on staff responsibilities for providing proper care and supervision to clients, proof of training with staff name and signature need to be submitted to CCLD by POC date.
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Based on records review and interview, the licensee did not comply with the section cited above, R1 who live at the memory care department was found at the facility’s parking lot by a resident’s family member, this posed potential health and safety risk to resident in care.
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Type B
06/17/2022
Section Cited
CCR87211(a)(1)

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Reporting Requirements. A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified... This requirement was not met as evidence by:
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Administrator agreed to provide staff re-training on reporting requirement, proof of training with staff name and signature need to be submitted to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not submitting incident report to CCLD which poses a potential health and safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/10/2022 07:23 PM - It Cannot Be Edited


Created By: Leslie Ibo On 06/10/2022 at 06:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MERRILL GARDENS AT BRENTWOOD
FACILITY NUMBER: 079201165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2022
Section Cited
CCR
87355(e)(2)

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Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline. This requirement is not met as evidenced by:
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Cleared and corrected during the visit.
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Based on record review, the licensee did not comply with the section cited above, S2 was not associated to the facility before starting to work which poses a potential health and safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


LIC809 (FAS) - (06/04)
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