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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 05/29/2024
Date Signed: 05/29/2024 05:23:16 PM


Document Has Been Signed on 05/29/2024 05:23 PM - 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 GILROYFACILITY NUMBER:
435202806
ADMINISTRATOR:NELSON RODRIGUESFACILITY TYPE:
740
ADDRESS:7610 ISABELLA WAYTELEPHONE:
(206) 676-5300
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:214CENSUS: 144DATE:
05/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Kippie CastronovoTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with General Manager, Kippie Castronovo.

During today's visit, LPA was verbally informed of a resident (R1's) death on 05/25/2024.
Based on record review and interview, the facility did not notify the Department of R1's death within 24 hours of the occurrence date.

R1's documents were requested by tomorrow (05/30/2024) morning: physician's report, needs and services plan, identification and emergency information, and progress notes for May 2024.

Documents were obtained during visit to include the incident report, police case number, and coroner's case number.

This case management visit will be pending investigation.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with General Manager, Kippie Castronovo and a copy of the report and appeal was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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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Document Has Been Signed on 05/29/2024 05:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/30/2024
Section Cited
CCR
87211(a)(2)

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by:
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Licensee will submit the training documentation to LPA Dolores via email by POC due date.
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Based on interview, record review, and observation the licensee did not ensure to report the resident (R1)'s death and incident to the department within 24 hours which poses / posed 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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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