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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201165
Report Date: 12/23/2024
Date Signed: 03/14/2025 08:01:48 AM

Substantiated


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
05/23/2024 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240523140613
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: DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Lydia Hertzler, General Manager/AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff do not provide adequate care and supervision to the residents
INVESTIGATION FINDINGS:
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On on12/23/2024 Licensing Program Analysts (LPAs) T. Syess-Gibson and L.Hall arrived unannounced to deliver finding on the above allegation and met with Lydia Hertzler. LPAs explained to Lydia Hertzler the purpose of the visit.
It was alleged that staff do not provide adequate care and supervision to the residents.
During the course of investigation, LPAs L. Fontanilla and T. Syess-Gibson interviewed staff and obtained the following records: May 2024 staff schedule, shower and laundry schedules, evaluation and Physician’s Reports.
Based on interviews conducted with staff on 5/30/2024, the Memory Care unit has 19 residents, 2 caregivers each for AM and PM shifts, one Activity staff and one Medication Technician (MedTech). The MedTech sets up and passes medications for both the assisted living and memory care. Housekeeping is done once a week by the housekeeping staff. The care staff are responsible in assisting residents with activities of daily living (ADLs) including but not limited to giving showers, making beds, serving breakfast and lunch, assisting residents during mealtimes, feeding resident, if needed, tidying up residents’ rooms, washing/rinsing cups/utensils after each meal, and doing daily laundry for 2-3 residents daily.
Substantiated
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: 1 of 3
Control Number 15-AS-20240523140613
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MERRILL GARDENS AT BRENTWOOD
FACILITY NUMBER: 079201165
VISIT DATE: 12/23/2024
NARRATIVE
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Continued LIC9099

The activity staff assists residents during mealtimes. If one care staff needs to go on break or does not show up, there is only one caregiver available to assist residents with ADLs. Sometimes, the Med Techs assist residents with ADLs, if available.

A review of the facility’s staff schedule for May 2024 shows that on May 12, 2024, only S4 worked in the morning shift. S4 confirmed with LPAs the information. When asked by LPAs how S4 managed to provide ADLs to all the residents, S4 states that it was impossible to provide all ADLs to all the residents. S4 states no residents were provided with showers and housekeeping. S4 added that although the Activity Director assisted during mealtimes and watched residents in the common areas, it was only S4 who provided care to all the residents in the unit.

On 5/22/2024 when Resident 1 (R1) had a bowel accident, S4 was on break and one caregiver was with another resident. R1’s daughter requested assistance in cleaning up R1. There was no staff available to assist R1. R1’s daughter ended up giving R1 a shower to get cleaned.

Staff interviewed state that there is one resident who needs 2-person assist (due to weight), 3 residents who wander and need constant redirection, 4 residents need two persons assist with showers/changing (due to behavior), 1 resident needs to be fed and 4 residents on hospice.

Based on interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

Health and Safety Code 1569.269(a)(6) is being cited on the attached LIC 9099D.



Exit interview was conducted with Lydia Hertzler and Appeal Rights was provided.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240523140613
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MERRILL GARDENS AT BRENTWOOD
FACILITY NUMBER: 079201165
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2024
Section Cited
HSC
1569.269(a)(6)
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1569.269(a)(6) Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs
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General Manager agreed to hire additonal staff along with a stafifng agency to have sufficent staff for facility, and submit new staff names and name of staff agency to CCLD by POC date. Deficiency cleared during visit.

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This requirement is not met as evidenced by: Based on interviews conducted, The LIcensee did not comply with the section cited above in having sufficent staff to provide care for the residents which poses a potential risk to the health and safety of the residents under 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3