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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201165
Report Date: 08/28/2025
Date Signed: 08/28/2025 04:02:04 PM

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
08/25/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250825144339
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: 112DATE:
08/28/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lydia Hertzler, Executive DirectorTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff did not respond to resident's calls for assistance in a timely manner
INVESTIGATION FINDINGS:
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On 08/28/2025 at 10:30AM, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegation above. LPA met with Lydia Hertzler, Executive Director, and explained the reason for the visit.


During the course of the investigation, LPA interviewed 2 staff, and 3 residents. LPA reviewed and obtained documents including resident roster, staff schedule, staff in service training memo with signatures of participants, staff contact number and facility’s call button/pendant response time report.

Continue on LIC9099C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
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-20250825144339
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: 08/28/2025
NARRATIVE
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Continued from LIC9099


Staff did not respond to resident’s calls for assistance in a timely manner
Interviews with R1, S1, S2 and record review revealed that R1’s call for assistance was not responded to in a timely manner. R1 stated she pressed the call button around 11:00pm and staff arrived after 4:00am. Record review revealed that R1’s call button was initiated at 11:24pm on 08/23/2025 and the response time was 5:22am on 08/24/2025.


Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.


Exit interview conducted with Lydia Hertzler. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250825144339
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: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/04/2025
Section Cited
CCR
87411(a)
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Personnel Requirements - General
Facility personnel shall at all times be sufficient in numbers...to provide the services necessary...In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care...

This requirement is not met as evidenced by:
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Executive Director (ED) held an in-service training course with staff on August 25, 2025, regarding understanding of facility’s policy pertaining to response time for call buttons and pendants. Deficiency cleared during visit.
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Based on investigation, the licensee did not comply with the section cited above by not responding to call button in a timely manner 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3