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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 08/20/2021
Date Signed: 08/20/2021 05:03:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MERRILL GARDENS AT GILROYFACILITY NUMBER:
435202806
ADMINISTRATOR:ATKINSON, DIANEFACILITY TYPE:
740
ADDRESS:7610 ISABELLA WAYTELEPHONE:
(206) 676-5300
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:214CENSUS: 139DATE:
08/20/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Diane AtkinsonTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Christine Dolores and Licensing Program Manager (LPM) Jackie Jin arrived unannounced to conduct a pre-licensing visit. LPA and LPM met with Diane Atkinson, Administrator.

There is currently residents living at the facility. The facility has three floors in assisted living, one floor memory care, and one transition memory care unit. The facility has an approved fire clearance for 199 non ambulatory and 15 bedridden residents.

LPA toured the facility inside and outside including the apartments, bathrooms, kitchen, and common areas. Resident apartments were equipped with proper furniture and lighting. Resident apartment temperature was maintained between 75 to 77 degrees Fahrenheit. Bedding and linens are available to the residents and observed clean. Bathrooms are equipped with grab bars, nonskid floors, hygiene supplies, and toiletry. Facility is equipped with cups, plates, utensils, and cooking supplies. Hot water temperature was measured between 105.4 to 114.2 degrees Fahrenheit in resident apartment bathrooms.

The facility has designated medication rooms with locked medication cabinets. LPA and LPM reviewed centrally stored medication records with residents medications. LPA observed first aid kit with the following supplies: bandages, scissors, tweezers, and thermometer.

LPA and LPM observed locked medications, sharp objects, and cleaning supplies.

Continue on LIC-809C
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MERRILL GARDENS AT GILROY
FACILITY NUMBER: 435202806
VISIT DATE: 08/20/2021
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LPA observed 2 days worth of perishables and 7 days worth of nonperishable. Refrigerator temperature was maintained at 37 degrees Fahrenheit. Freezer temperature was maintained at 0 degrees Fahrenheit.

Facility is equipped with smoke detectors, carbon monoxide detector, and fire extinguisher. Hallway and passageways were observed free of obstruction.

LPA and LPM will return another day to complete pre-licensing visit.

This report was reviewed with Diane Atkinson, Administrator, and a copy of this report is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
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