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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202572
Report Date: 10/28/2024
Date Signed: 10/28/2024 04:14:53 PM

Document Has Been Signed on 10/28/2024 04:14 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/
DIRECTOR:		BRADLEY, BURGOYNEFACILITY TYPE:
740
ADDRESS:2115 S WINCHESTER BLVDTELEPHONE:
(408) 370-6454
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 166CENSUS: 148DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator, Bradley BurgoyneTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection visit at 9:15 AM and met with Administrator, Bradley Burgoyne. LPA toured the facility inside and out with the Administrator to include the resident dining room, kitchen, resident bedrooms, bathrooms, and exterior. Facility temperature maintained between 71 to 72 degrees F. Facility staff are fingerprint cleared and associated to facility. All emergency exits were observed to be clear of obstruction.

LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature maintained at 35 degrees F and freezer maintained at -1 degrees F. The exterior of the facility was also inspected. No toxins, chemicals or items that can pose a danger to residents observed.

LPA Tarin toured 7 resident bedrooms. 7 out of 7 resident bedrooms had functioning lights, storage space for personal belongings, clean bedding, a chair, lamp and dresser/table. LPA measured hot water temperature, with a range of 113.7 to 114.2 degrees F for 7 out of 7 resident bathrooms.

The facility was equipped with smoke and carbon monoxide detectors, and last serviced on 10/24/2024. Fire extinguishers were last serviced on 04/23/2024. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake drill log was reviewed and drills are being conducted quarterly. The last fire drill was conducted on 09/24/2024. Facility has emergency disaster plan.

LPA reviewed 7 residents Centrally Stored Medication and Destruction Records (CSMDR). LPA observed 7 out of 7 CSMDRs are complete with all medications accounted and documented. LPA observed the medication storage area was locked and inaccessible to residents in care.

Please see LIC 809-C.
Jin Jackie
Marcella Tarin
DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CAMPBELL
FACILITY NUMBER: 435202572
VISIT DATE: 10/28/2024
NARRATIVE
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LPA reviewed 7 resident records. LPA observed 5 out of 7 resident records as complete to include a physician's report,TB result, updated appraisal/needs and services plan, identification and emergency contact information, personal rights, and consent forms. Resident (R2 and R3) records did not contain updated physician's reports. Resident R2 and R3 physician's reports were not updated within the year. R2 and R3 have neurocognitive disorder. LPA advised Administrator to obtain updated physician's reports for Residents R2 and R3.

LPA reviewed 8 staff records. LPA observed 8 out of 8 records to include fingerprint clearance, health screening, TB result, and personnel record. 3 out of 8 staff (S2, S6, and S7) records did not contain CPR/first aid training. LPA advised Administrator that staff who assist residents with personal activities of daily living shall receive appropriate training in CPR/first aid.

Deficiencies were cited today per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Bradley Burgoyne. A copy of this report was provided to Administrator and Appeal Rights were provided.
SUPERVISOR'S NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2024 04:14 PM - It Cannot Be Edited


Created By: Marcella Tarin On 10/28/2024 at 03:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MERRILL GARDENS AT CAMPBELL
FACILITY NUMBER: 435202572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above. LPA observed 3 out of 8 staff (S2, S6, and S7) records did not contain CPR/first aid training, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Administrator states the facility will conduct an audit of staff records, and will have CPR/First Aid training for staff completed by November 1st. Administrator states facility will submit POC to LPA Tarin by POC due date 10/29/2024.
Type A
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above. Resident (R2 and R3) records did not contain updated physician's reports within the year. R2 and R3 have neurocognitive disorder which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Administrator stated facility will contact resident's responsible party to obtain updated physician's reports for R2 and R3. Administrator states facility will submit POC to LPA Tarin by POC due date 10/29/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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