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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201165
Report Date: 12/17/2024
Date Signed: 12/23/2024 01:09:52 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
12/10/2024 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241210103140
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: 121DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Lydia Hertzler, General ManagerTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is short staff.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Amended to remove two unsubstantiated allegations.

On 12/17/2024 at 10:13am, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to conduct the 10-day initial visit for the above allegations. LPA met with Lydia Hertzler, General Manager (GM), and explained the reason for the visit.

During the visit LPA interviewed staff, residents, obtained and reviewed LIC500 (personnel record) and resident roster.

Allegation: Facility is short staff
During interview with S1, S2, and S3, it was determined that the facility had a lot of Staff calling out, which calls for other Staff members to fill in on Assisted LIving side. S3 stated faciilty has since hired two (2) medtechs and two (2) caregivers. Facility has also obtained contracts with the All Phases and Allegra staffing agencies.Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur,therefore the allegation is UNSUBSTANTIATED.
Exit interview conducted and a copy of this report provided.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
12/10/2024 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241210103140

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: 121DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Lydia Hertzler, General ManagerTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not treating residents with dignity and respect.
Facility is unsecured.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Amended to remove Substantiated allegation

On 12/17/2024 at 10:13am, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to conduct the 10-day initial visit for the above allegations. LPA met with Lydia Hertzler, General Manager (GM), and explained the reason for the visit.

Allegation: Staff not treating residents with dignity and respect.
During interview with Staff 1 (S1), Staff 2 (S2), Staff (S3), Resident 1 (R1) Resident (R2) and Resident (R3) it was stated that all residents are treated with dignity and respect.

Allegation: Facility is unsecured.
During interviews with Staff 1 (S1) and Staff 2 (S2), it was determined that the facility only has one point of entrance which is through the main entrance of the building. The doors are open between the hours of 7am-7pm, after 7pm residence or staff would have used their key fob to enter the building.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED.
No deficiencies are being cited on this date. Exit interview conducted and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2