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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202572
Report Date: 11/08/2024
Date Signed: 11/08/2024 11:51:22 AM

Document Has Been Signed on 11/08/2024 11:51 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
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: 166TOTAL ENROLLED CHILDREN: 0CENSUS: 150DATE:
11/08/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Administrator, Bradley BurgoyneTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a case management to follow up on deficiencies that were cited on 10/28/2024. LPA Tarin met with Administrator (ADM) Bradley Burgoyne.

On 10/28/2024, LPA Tarin conducted the facility's annual inspection. During resident record review, LPA Tarin observed Resident records for R2 and R3, 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. During staff record review, LPA Tarin observed 3 out of 8 staff (S2, S6, and S7) records did not contain CPR/first aid training.

During today's visit, LPA Tarin reviewed documentation for S2 and S7 to have completed CPR/First Aid training on 10/28/2024. ADM stated S6 has completed the CPR/First Aid training, but has not obtained the certificate. ADM states the facility will email a copy of S6's CPR/First Aid training once it is obtained.

LPA Tarin reviewed updated physician's reports for R2, updated on 09/24/2024. ADM states R3 had a video appointment with his/her physician on 11/7/2024, and is awaiting a copy of the updated physician's report. ADM states the facility will email a copy of R3's updated physician's report once it is received.

LPA Tarin cleared the deficiencies cited on 10/28/2024 during today's visit. A Letter of Deficiency Citations Cleared was printed and provided to ADM.

No deficiencies were cited during todays visit. A copy of this report was provided to ADM Bradley Burgoyne.
Jin JackieTELEPHONE: (714) 319-3786
Marcella TarinTELEPHONE: (714) 328-5152
DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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