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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202806
Report Date: 10/29/2024
Date Signed: 10/29/2024 02:35:03 PM

Substantiated


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
10/10/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20231010113934
FACILITY NAME:MERRILL GARDENS AT GILROYFACILITY NUMBER:
435202806
ADMINISTRATOR:NELSON RODRIGUESFACILITY TYPE:
740
ADDRESS:7610 ISABELLA WAYTELEPHONE:
(206) 676-5300
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:214CENSUS: DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Billy MitchellTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Facility's call button is not operable and reachable to the resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the complaint investigation findings. LPA met with General Manager, Billy Mitchell.

On 10/10/2023, the Department received the complaint. On 10/18/2023, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include resident (R1)’s physician’s report, hospice paperwork, POLST, service plan, progress notes, POA documents, personal rights form, alert button logs, and death report.

It was alleged that the facility’s call button is not operable and reachable to the resident as resident (R1)’s family member pressed the call button, and no one answered. It was also alleged that the call button is too far of reach from R1’s bed. PAGE 1 OF 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 26-AS-20231010113934
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 GILROY
FACILITY NUMBER: 435202806
VISIT DATE: 10/29/2024
NARRATIVE
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On 10/18/2023, LPA Dolores entered into R1’s bedroom. R1’s bed was removed as R1 passed away early morning of 10/18/2023. LPA observed an alert button on the wall that was placed above the night stand. Based on interview with staff (S1) and (S2), R1’s bed was located to the right of the night stand.

LPA observed that the alert button may not be of arms reach if a person is laying down in bed. The alert button did not contain a pull cord. Based on interview with S2, S2 stated that R1 was not able to reach the button.

LPA Dolores pressed the alert button above the night stand at 2:34PM and there was no response from staff at 2:45PM (11 minutes after the alert button was pressed).

At 2:39PM, LPA entered room #2 located right next to R1’s room. At 2:39PM, LPA pressed the alert button next to the bed. 2:41PM, S1 pushed the alert button in the bathroom. 2:42PM, LPA Dolores pressed the alert button next to the bed a second time. At 2:45PM, there was no response from staff.

Based on record review, R1’s alerts were not responded to on 10/07/2023, 10/08/2023, 10/10/2023, 10/12/2023, 10/15/2023, 10/17/2023, and 10/18/2023 (7 different occasions).

The Department has investigated the above allegation. Based on record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated.

A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D.

This report was reviewed with General Manager, Billy Mitchell and a copy of the report and appeal rights was provided.

PAGE 2 OF 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20231010113934
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 GILROY
FACILITY NUMBER: 435202806
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2024
Section Cited
CCR
87468.2(a)(4)
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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
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Licensee will conduct a staff training regarding responding to call buttons in Garden House (aka Memory Care). Licensee will submit the training document to LPA Dolores via email by POC due date.
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Based on interview, record review and observation the licensee did not comply with the section cited wherein R1's alert button was not responded to on 7 different occasions and based on LPA Dolores observation on 10/18/23 which poses an immediate health, safety, and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
10/10/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20231010113934

FACILITY NAME:MERRILL GARDENS AT GILROYFACILITY NUMBER:
435202806
ADMINISTRATOR:NELSON RODRIGUESFACILITY TYPE:
740
ADDRESS:7610 ISABELLA WAYTELEPHONE:
(206) 676-5300
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:214CENSUS: DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Billy MitchellTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Facility staff did not honor residents wishes to go to the hospital
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the complaint investigation findings. LPA met with General Manager, Billy Mitchell.

On 10/10/2023, the Department received the complaint. On 10/18/2023, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include resident (R1)’s physician’s report, hospice paperwork, POLST, service plan, progress notes, POA documents, personal rights form, alert button logs, and death report.

It was alleged that the facility staff did not honor resident (R1)’s wishes to go to the hospital on 10/10/2023. PAGE 1 OF 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 26-AS-20231010113934
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 GILROY
FACILITY NUMBER: 435202806
VISIT DATE: 10/29/2024
NARRATIVE
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Based on record review, R1 was under hospice care. On 10/10/2023, R1’s family member called 911 and the paramedics and police arrived to the facility. Based on interview with S2, R1’s family member called 911 because R1 was not feeling well.
The paramedics arrived to the facility and assessed R1 and R1 verbalized that he/she wanted to stay and did not want to go to the hospital.

S2 states the facility was instructed by R1’s hospice team to call 911 if the resident sustains an injury like a fall.

The review of R1’s records indicates that R1 was a DNR and on comfort focused treatment.

The Department has investigated the above allegation. Based on interview and record review the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided.

PAGE 2 OF 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
10/10/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20231010113934

FACILITY NAME:MERRILL GARDENS AT GILROYFACILITY NUMBER:
435202806
ADMINISTRATOR:NELSON RODRIGUESFACILITY TYPE:
740
ADDRESS:7610 ISABELLA WAYTELEPHONE:
(206) 676-5300
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:214CENSUS: DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Billy MitchellTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Facility staff is not accepting resident's POA documents
Facility staff does not allow resident to have a voice in memory care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the complaint investigation findings. LPA met with General Manager, Billy Mitchell.

On 10/10/2023, the Department received the complaint. On 10/18/2023, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include resident (R1)’s physician’s report, hospice paperwork, POLST, service plan, progress notes, POA documents, personal rights form, alert button logs, and death report.

It was alleged that the facility is not accepting the resident’s POA (power of attorney) documents as the facility did not check the validity of the second POA paperwork that was provided. It was alleged that the facility just took the POA documents from one of R1’s family members, when another one of R1’s family members has POA documents that is dated more recently. PAGE 1 OF 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20231010113934
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 GILROY
FACILITY NUMBER: 435202806
VISIT DATE: 10/29/2024
NARRATIVE
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Based on record review, the facility obtained both POA documents from two of R1’s family members. The first POA document is dated in 2020 and the second POA document is dated in 2023.

Based on interview, S1 and S2 states they received two POA documents from both family members. The second POA document dated 2023 was when R1 already had dementia. S2 states they were using the initial POA documents while pending further clarification from the facility’s corporate office on if the second POA document was valid as it was dated when R1 already had dementia.

It was alleged that the facility staff does not allow R1 to have a voice in memory care because R1 sits with the same person during meals every day and R1 does not even like the person he/she sits with. It was alleged that the staff does not listen to R1 because R1 has Dementia.

Based on staff interview, R1 did not have a preference of who he/she wanted to eat with. R1 would agree with whoever family member is in the room. R1 did not verbalize that he/she wanted to sit with certain residents or staff during mealtime.

The Department has investigated the above allegations. Based on interview and record review, the above allegations are unfounded meaning the allegations are false, could not have happened, and/or is without a reasonable basis.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7