<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202572
Report Date: 05/02/2024
Date Signed: 05/02/2024 04:36:45 PM


Document Has Been Signed on 05/02/2024 04:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:MERRILL GARDENS AT CAMPBELLFACILITY NUMBER:
435202572
ADMINISTRATOR:BRADLEY, BURGOYNEFACILITY TYPE:
740
ADDRESS:2115 S WINCHESTER BLVDTELEPHONE:
(408) 370-6454
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:166CENSUS: 154DATE:
05/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Bradley BurgoyneTIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Incident visit and met with Bradley Burgoyne. The purpose of the visit was to follow up with an incident self-reported by the facility in which staff S1 was allegedly observed to have hit resident R1 on the back of the head.

During visit, LPA Marrufo obtained resident records for R1 and training records for S1. Staff S1 was not present during visit and was not interviewed.

During visit, LPA Marrufo conducted a wellness check and observation of R1.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Bradley Burgoyne and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1