435202572-1-2-2026-26-AS-CKAI-DQ6VLD-20260109153142

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202572
Report Date: 01/02/2026
Date Signed: 01/02/2026 02:47:58 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/19/2025 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20250619095310

FACILITY NAME:	MERRILL GARDENS AT CAMPBELL		FACILITY NUMBER:	435202572
ADMINISTRATOR:	BRADLEY, BURGOYNE		FACILITY TYPE:	740
ADDRESS:	2115 S WINCHESTER BLVD		TELEPHONE:	(408) 370-6454
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	166	CENSUS: 146	DATE:	01/02/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	General Manager (GM) Alex Den		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility did not ensure resident was observed regularly
Facility did not provide eviction letter
Facility did not allow 1:1 private care for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to deliver the findings of a complaint received by the Department on 6/19/2025. LPA met with General Manager (GM) Alex Den. LPA stated the purpose of the visit.

On 6/25/2025 and 10/14/2025 complaint investigation visits were conducted.

On 6/25/2025, LPA Tarin interviewed Reporting Party (RP). RP states the facility is not assessing Resident (referred to as R1). RP states the facility did not know R1 has neurocognitive disorder. RP states R1 had an incident that caused water damage to the facility in February 2025, and the facility requested an updated physician's report for R1 due to this incident.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250619095310

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/02/2026

NARRATIVE

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LPA interviewed General Manger (GM) Alex Den. GM states R1 was reassessed by the facility on 2/3/2025 when R1 was observed to be confused while walking around the facility. GM states R1 also had an incident that caused water damage to the facility in February 2025.

LPA interviewed 1 Staff (S1). S1 states he/she reassessed R1 on 2/3/2025 when R1 was observed to be confused while walking in the facility, an observed change of condition. S1 states extra support for R1 to include reminders, redirection and staff checking on R1 every 2 hours began on 2/9/2025.

LPA interviewed 11 Residents (R1 to R11). 11 Out of 11 residents stated they have no issues or concerns with the care they are receiving.

Based on review of documentation, R1’s physician’s reports are dated 4/21/2016, with R1’s mental condition listed as able to follow instructions, able to communicate needs, able to leave unassisted. No diagnosis or medical conditions listed. R1’s physician’s report dated 2/6/2025 states R1’s has diagnosis of major neurocognitive disorder, and mild cognitive impairment. Review of an additional medical assessment of R1 was conducted on 3/27/2025, which noted R1 to have mixed neurocognitive disorder.

Facility did not provide eviction letter
It has been alleged by the RP that the facility did not provide an eviction letter to R1. RP states the facility verbally tried evict R1 on 6/18/2025, if R1 did not move into the memory care within the facility. RP states he/she requested the eviction in writing, and the facility did not provide an eviction notice.

LPA interviewed GM. GM states he/she met with RP and had a 'chat' and a recommendation was made for R1 to move into memory care. GM states R1 was not being evicted.

LPA interviewed S1. S1 states there was never any eviction for R1, only a recommendation for R1 to move into memory care, which was shared with RP during a care conference.

LPA interviewed 11 Residents (R1 to R11). 11 Out of 11 residents stated they have no issues or concerns with the care they are receiving.
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SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250619095310

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/02/2026

NARRATIVE

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Facility did not allow 1:1 private care for resident
It has been alleged by the RP that the facility did not allow 1:1 care for R1 in February 2025 when R1 caused water damaged at the facility. RP states he/she was told by GM that 1:1 care was not allowed.

LPA interviewed GM. GM states R1 is receiving additional support from staff after the incident of water damage by R1 in February 2025. GM states RP did not allow recommended 1:1 care for R1 on multiple occasions. GM did not remember dates of this incident.

LPA interviewed S1. S1 states R1 has been provided additional staff support since 2/9/2025 to include reminders, redirection and staff checking on R1 every 2 hours. S1 did not provided additional information regarding 1:1 care for R1.

LPA interviewed 11 Residents (R1 to R11). 11 Out of 11 residents stated they have no issues or concerns with the care they are receiving.

Based on review of documentation, R1 has been receiving additional staff support since 2/9/2025.

Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC9099 (FAS) - (06/04)

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