Inspection Reports for Merrill Gardens at Lafayette
1010 Second St, Lafayette, CA 94549, CA, 94549
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on April 23, 2025, which was perfect with all safety equipment and emergency plans in place. Several complaint investigations were unsubstantiated, such as allegations about delayed medical attention, unlawful eviction, staffing shortages, and staff misconduct. One substantiated complaint from September 30, 2021, involved a violation of residents’ personal rights because the facility failed to formally address a resident’s repeated smoking in violation of policy over several years. The facility took immediate corrective actions in a separate incident involving a staff member’s HIPAA violation in August 2022, but no fines or enforcement actions were listed in the available reports. Overall, the facility’s record shows mostly compliance with isolated issues that have been addressed, and recent inspections indicate improvement and adherence to regulations.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
0.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
95% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
87% occupied
Based on a April 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 87
Capacity: 100
Deficiencies: 0
Date: Apr 23, 2025
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.
Findings
The Licensing Program Analyst toured the facility and reviewed resident and staff records. All safety equipment and emergency plans were in place and operational. No deficiencies were cited during the visit.
Report Facts
Residents records reviewed: 5
Staff records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamal Singh | General Manager | Met with Licensing Program Analyst during inspection |
| David Doidge | Licensing Program Analyst | Conducted the inspection |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 100
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not seek medical attention for a resident in a timely manner resulting in injuries and that staff unlawfully evicted a resident.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to seek timely medical attention and unlawful eviction of a resident. The resident was independent and declined ambulance transport after a fall. Staff followed protocols and the resident was later hospitalized. There was insufficient evidence to prove violations occurred.
Findings
The investigation found that staff followed proper fall protocols and that the resident declined ambulance assistance at the time of the fall. The resident was later hospitalized with rib fractures and other injuries. The complaints were determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 100
Census: 90
Complaint control number: 15-AS-20240530105952
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Clark | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Troy Beaton | Resident Care Director | Met with investigators during the visit |
| Jillian L Hunter | Administrator | Facility administrator named in report header |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 100
Deficiencies: 0
Date: Jun 3, 2024
Visit Reason
The inspection was conducted as a result of a priority 1 complaint to perform a Health & Safety inspection at the facility.
Complaint Details
The visit was triggered by a priority 1 complaint. No deficiencies were cited during the visit.
Findings
The Licensing Program Analysts toured the facility and found no deficiencies. Hot water temperature, food supplies, medication storage, smoke and carbon monoxide detectors, first-aid kit, and fire extinguisher were all in compliance. Passageways were free of obstruction.
Report Facts
Hot water temperature: 117.2
Non-perishable food supply duration: 7
Perishable food supply duration: 2
Fire extinguisher last serviced: Sep 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Troy Beaton | Resident Care Director | Met with Licensing Program Analysts during inspection |
| Greg Clark | Licensing Program Analyst | Conducted the Health & Safety inspection |
| Ardalan Gharachorloo | Licensing Program Analyst | Conducted the Health & Safety inspection |
Inspection Report
Annual Inspection
Census: 90
Capacity: 100
Deficiencies: 0
Date: May 21, 2024
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.
Findings
The Licensing Program Analysts toured the facility and reviewed resident and staff records, finding no deficiencies. Safety equipment and emergency plans were in place and operational.
Report Facts
Hot water temperature: 115.5
Fire extinguisher last serviced: Sep 14, 2023
Emergency disaster plan last posted: Apr 3, 2024
Emergency disaster drill last conducted: May 16, 2024
Residents records reviewed: 5
Staff records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Clark | Licensing Program Analyst | Conducted the inspection |
| Aubrey Goo | Interim Administrator | Met with Licensing Program Analysts during inspection |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 100
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that a staff member yelled at and verbally threatened another co-worker in front of residents at the facility.
Complaint Details
The complaint alleged that a staff member yelled at and verbally threatened a co-worker in front of residents. The complaint was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Findings
The investigation found that a verbal altercation occurred between two staff members on 05/21/2023, but no residents were present during the incident and residents were not aware of it. The complaint was determined to be unfounded and was dismissed.
Report Facts
Staff interviewed: 6
Residents interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jillian Hunter | General Manager | Met with Licensing Program Analyst during the investigation |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 100
Deficiencies: 0
Date: Jan 26, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-05-11 alleging that staff were not available to meet resident needs.
Complaint Details
The complaint alleged that staff were not available to meet resident needs. The investigation was unannounced and included interviews and document reviews. The allegation was found to be unsubstantiated.
Findings
The investigation found that the facility had sufficient staffing for all three shifts, residents were calm and comfortable, and residents reported no issues with staff availability. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 100
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William Beaton | Resident care director (nurse) | Met with Licensing Program Analyst during investigation |
| Jillian Hunter | Executive Director | Participated in exit interview |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 100
Deficiencies: 0
Date: Aug 29, 2022
Visit Reason
The visit was an unannounced case management inspection conducted due to a self-reported incident involving a staff member's violation of HIPAA.
Complaint Details
The complaint involved a staff member (S1) violating HIPAA by mishandling facility property including photos. The incident was substantiated with police involvement and corrective actions taken by the facility.
Findings
The investigation found that the incident was reported to the police, and the staff member returned most property except photo albums. The administrator took immediate corrective actions including deactivating access and terminating the staff member. No health or safety impacts to residents were identified and no deficiencies were cited during the visit.
Report Facts
Capacity: 100
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jillian Hunter | Administrator | Administrator who took corrective actions and was present during the visit |
| Catherine Lin | Licensing Program Analyst | Conducted the unannounced case management visit |
| Bennett Fong | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Routine
Census: 95
Capacity: 100
Deficiencies: 0
Date: May 17, 2022
Visit Reason
The visit was an unannounced routine Infection Control Inspection conducted to assess compliance with infection control protocols.
Findings
The facility was found to be in compliance with infection control requirements, including proper PPE use, screening procedures, and adequate supplies of food and PPE. No deficiencies were cited during the visit.
Report Facts
Food supply duration: 2
Food supply duration: 7
PPE supply duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aubrey Goo | Administrator | Met with Licensing Program Analyst during inspection |
| Catherine Lin | Licensing Program Analyst | Conducted the Infection Control Inspection |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 100
Deficiencies: 1
Date: Sep 30, 2021
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 09/24/2021 regarding staff not preventing a resident from smoking in violation of facility policy.
Complaint Details
The complaint alleging staff did not prevent a resident from smoking was substantiated based on interviews and record reviews.
Findings
The investigation found that for over three years, staff and residents informed management about Resident R1 smoking on their balcony despite a no-smoking policy. The facility did not issue a formal warning to the resident or their authorized representatives, constituting a violation of residents' personal rights.
Deficiencies (1)
Failure to comply with CCR 87468.1(a)(2) regarding residents' personal rights to safe, healthful, and comfortable accommodations; management was informed of resident smoking multiple times over three years but did not issue a formal warning.
Report Facts
Capacity: 100
Census: 92
Deficiency Type: Type B
Plan of Correction Due Date: Oct 4, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison O'Hollaren | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Aubrey Goo | Administrator | Facility administrator interviewed during the investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw the licensing program and signed the report |
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