435202806-4-13-2022-26-AS-KHOS-CDWPKY-20220428112356

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202806
Report Date: 04/13/2022
Date Signed: 04/13/2022 01:34:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/12/2021 and conducted by Evaluator Christine Dolores

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20211012093855

FACILITY NAME:	MERRILL GARDENS AT GILROY		FACILITY NUMBER:	435202806
ADMINISTRATOR:	ATKINSON, DIANE		FACILITY TYPE:	740
ADDRESS:	7610 ISABELLA WAY		TELEPHONE:	(206) 676-5300
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	214	CENSUS:	DATE:	04/13/2022
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	DIANE ATKINSON		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Resident's grooming needs are not being met.
Staff did not safeguard resident's personal belongings.
Staff did not seek medical attention in a timely manner.
Facility is charging for services not rendered.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced complaint visit to deliver the findings of the above complaint allegation. LPA met with Executive Director, Diane Atkinson.

From 10/15/2021 – 03/16/2022, LPA obtained the following documents to include: 5 residents (R1 – R5) physician reports, needs and services plan, safeguard personal property and valuables (LIC-621), POA information, financial service statements, invoices dated 11/01/2021, R3’s communication notes from 05/01/2021 – 08/31/2021, facility’s staff roster, staffing scheduling for assisted living from 06/01/2021 – 09/31/2021, established fee and services, evaluation guidance and terminology, and residency and services agreement.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

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-20211012093855

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/13/2022

NARRATIVE

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Resident’s grooming needs are not being met

On 10/15/2021, a total of 5 residents (R1 – R5) were interviewed. 5 out of 5 residents did not indicate their grooming needs were not met and did not have any concerns on grooming needs. 4 of the 5 residents states to have a beauty salon at the facility but states to be closed. 1 out of 5 residents was not able to answer the question. 3 out of 5 residents stated to get their grooming service from outside salons. 2 out of 5 residents could not remember how they are getting their grooming service. During interview, LPA observed 5 out of 5 residents to be well groomed with combed hair and clean shave.

On 12/28/2021, a total of 4 staff (S1 – S4) were interviewed. 4 out of 4 staff states to have a beauty salon that is temporarily closed due to staffing. 4 out of 4 staff states to try their best to encourage resident’s grooming and hygiene needs but if residents refuse, they cannot force them. 4 out of 4 staff states that staff members do not cut the residents hair. 4 out of 4 staff states that resident’s families are contacted and involved with the resident’s grooming needs.

Based on interview, facility staff are not allowed to cut hair and cut nails but can assist resident’s with services to include but not limited to shaving, brushing teeth, and washing of the face. Resident and family member, if applicable, must consent to the services and sign the level of care reflected on the care plan prior to receiving services.

Based on record review, 5 out of 5 residents care plan does not include additional grooming services.

Staff did not safeguard resident’s personal belongings

On 10/15/2021, a total of 5 residents (R1 – R5) were interviewed. 4 out of 5 residents states no personal items have been gone missing in the facility. 1 out of 5 residents was not able to answer the question.

On 12/28/2021, a total of 4 staff (S1 – S4) were interviewed. 2 out of 4 staff states the Safeguard of Personal Property form is waived due to company policy.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20211012093855

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/13/2022

NARRATIVE

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2 out of 4 staff is not aware of the Safeguard of Personal Property form. 2 out of 4 staff states if residents are more independent, they are encouraged to secure their items or tag their items with their name on it, for example, clothing. 2 out of 4 staff states facility would communicate with family if items should be removed from a resident’s apartment due to a behavior. 1 out of 4 staff states to communicate and obtain permission from residents first before throwing out an item.

Based on record review, facility’s residency and service agreement states the community recommends residents to insure and/or engrave or mark belongings as items including by not limited to clothing, jewelry, and furniture are not covered by community’s insurance. A written inventory form of resident’s personal property will be maintained in resident’s file and a signed copy will be provided to resident and/or representative. 5 out of 5 resident’s personal property and valuables form was waived, signed, and dated.

Staff did not seek medical attention in a timely manner

On 10/15/2021, a total of 5 residents (R1 – R5) were interviewed. 3 out of 5 residents states to never had an incident needing medical attention at the facility. 1 of out 5 residents states to not have been an incident where staff did not provide medical attention needed. 1 out of 5 residents was not able to answer the question. 4 out of 5 residents states staff are helpful and are meeting their needs. 1 out of 5 residents was not able to answer the question.

On 12/28/2021, a total of 4 staff (S1 – S4) were interviewed. 4 out of 4 staff states to seek medical attention in a timely manner. 4 out of 4 staff states facility procedure to contact 911 when medical attention is needed. 3 out of 4 staff states to contact resident’s family to inform them of the situation. 1 out of 4 staff did not provide information on informing family members. S1 and S4 states that it is the resident’s rights to refuse medical treatment but will always contact family to inform them of the situation. S1 states if family members cannot take the resident to their doctor appointment, the facility will find a way to assist the resident to their appointment and have family meet them, if needed.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20211012093855

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/13/2022

NARRATIVE

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Based on record review, on 07/19/2021, facility staff contacted R3’s responsible party to inform of the increased altered mental status and recommendation to be seen by a physician. Responsible party agreed for resident to be taken to the emergency room. After paramedics arrived and assessed the resident, it was agreed by the paramedics and responsible party for resident to stay at the facility. Facility staff encouraged R3’s responsible party to see a primary care physician. On 07/20/2021, S1 contacted R3’s responsible party regarding the change of condition and responsible party agreed for resident to be taken to the emergency room. Ambulance was called and arrived at 1:00 p.m. to transport R3 to the hospital. On 07/22/2021, staff faxed R3’s primary care physician (PCP) requesting for an updated Physician’s Report with new diagnosis. On 09/28/2021, a care conference was held with facility staff, ombudsman, and R3’s responsible party regarding R3’s change of condition and plan of care. Based on record review, from 07/21/2021 – 10/31/2021, R3 did not require medical attention but required monitoring from staff.

Facility is charging for services not rendered

On 10/15/2021, a total of 5 residents (R1 – R5) were interviewed. 2 out of 5 residents states paying for additional services and receiving the services being paid. 2 out of 5 residents are independent and does not require additional services. 1 out of 4 residents was not able to state whether facility is charging for serviced not rendered. 4 out of 5 residents states no issue or concern regarding facility charging for services not rendered. 1 out of 4 residents was not able to answer the question.

On 12/28/2021, a total of 4 staff (S1 – S4) were interviewed. 3 out of 4 staff state residents are receiving the services being charged at the facility. 1 out of 4 staff was not familiar with the financial aspect but states to follow every resident’s care plan to show what type of care/service to provide. 4 out of 4 staff states facility assists the residents based on their care plan and Activities of Daily Living (ADLs).

Based on record review, the additional services are charged based on the facility’s service level point system during the health services evaluation, which is reflected on the resident’s care plan.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20211012093855

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/13/2022

NARRATIVE

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Fees and Services are associated depending on the level of services and care being provided (i.e., the amount, frequency and intensity of Assisted Living/Garden House Services). The level of care in Assisted Living/Garden House begins at Level 1/LevelGH1 and each additional level increases by a set amount each month.

2 out of 5 residents are under a level of care in which service charge reflects the correct amount based on the care plan service level points. 1 out of 5 residents is being charged 1 additional service. 2 out of 5 residents are not paying for additional services. 5 out of 5 residents are being charged the correct service charge amount based on their care plan needs.

The Department has investigated the above allegations. Based on interviews conducted and records reviewed, the Department has determined that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

This report was reviewed with Executive Director, Diane Atkinson and a copy of this report was provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

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