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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201165
Report Date: 12/23/2024
Date Signed: 01/07/2025 10:32:24 AM

Document Has Been Signed on 01/07/2025 10:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MERRILL GARDENS AT BRENTWOODFACILITY NUMBER:
079201165
ADMINISTRATOR/
DIRECTOR:		SHIELDS, JERYLFACILITY TYPE:
740
ADDRESS:2600 BALFOUR RDTELEPHONE:
(925) 297-6841
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 150CENSUS: 121DATE:
12/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Lydia Hertzler, General Manager/AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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On 12/23/2024 at 10:30AM Licensing Program analysts (LPAs) T. Syess-Gibson and L. Hall arrived unannounced to conduct a Case Management visit to provide the amended complaint from 12/17/2024. LPAs met with Lydia Hertzler, General Manager and explained the purpose of visit.

While LPA T. Syess-Gibson was conducting a complaint investigation 15-AS-20241210103140 on 12/17/2024, LPA added substantiated the allegation of Facility is short staff; however, all allegations should have been unsubstantiated. LPA amended LIC9099 and LIC9099A to show unsubstantiated allegations.


On 01/07/2025 at 10:00AM LPA T.Syess-Gibson arrived to deliver this report and obtain signature from facility representative which was generated on 12/23/2024

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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