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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 06/13/2024
Date Signed: 06/13/2024 01:35:24 PM


Document Has Been Signed on 06/13/2024 01:35 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: DATE:
06/13/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kim GoldenTIME COMPLETED:
01:40 PM
NARRATIVE
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On 06/13/2024 San Bruno Regional Office - San Jose Unit conducted a non-compliance conference meeting with Vice President of Operations Kim Golden, Legal Council (Hansen and Bridges) Joel Goldman, Vice President of Care Teri Moore-Showalter, Regional Director of Health Services Erika Hughes, and Garden House Director Jocelyne Bailon.

Present in the meeting were Regional Manage Vivien Helbling, Licensing Program Manager Jackie Jin, and Licensing Program Analyst Christine Dolores.
 
During the non-compliance meeting, the following serious violations were discussed: 87211(a)(2) Reporting Requirements, 87466 Observation of Resident, 87468.1(a)(2) Personal Rights of Residents in All Facilities, 87463(a)(3) Reappraisals, 87468.1(a)(3) Personal Rights of Residents in All Facilities, 87355(e)(2) Criminal Record Clearance, 87355(e)(1) Criminal Record Clearance, and 97705(f)(2) Care of Persons with Dementia.

During this meeting, the compliance plan was developed and discussed with the licensee which includes more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: 
https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers.

During this meeting, an additional deficiency was issued as per California Code of Regulations, Title 22 following deficiencies found during case management visits and complaint investigations: on 05/29/2024, licensee and Administrator failed to report a serious injury and resident's death within 24 hours to Licensing.
See LIC809-D for more information. Page 1 of 2.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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
VISIT DATE: 06/13/2024
NARRATIVE
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On 01/31/2023 and 12/08/2022, licensee and Administrator failed to associate 4 staff members to the facility's roster prior to staff members starting work resulting in a repeat violation within a 12 month period. On 06/12/2024 and 12/08/2022, licensee and Administrator failed to obtain a criminal record clearance for 2 staff members prior to the staff members starting work. On 01/16/2024, licensee and Administrator failed to ensure a resident's reappraisal was updated after returning to the facility from the hospital.

The current Administrator's last day at the facility is 06/14/2024.

An additional Civil Penalty for violation resulting in serious injury is pending review.

This report was reviewed with Vice President of Operations Kim Golden, Legal Council (Hansen and Bridges) Joel Goldman, Vice President of Care Teri Moore-Showalter, Regional Director of Health Services Erika Hughes, and Garden House Director Jocelyne Bailon. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/13/2024 01:35 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: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2024
Section Cited
CCR
87405(d)(2)

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(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
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Licensee will ensure that immediately, Administrator will be trained regarding Administrator Qualification, Duties and Responsibilities. Temporary Administrator is in place. Deficiency was corrected.
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Based on interview, record review, and observation the Administrator failed to exhibit the knowledge of applicable laws, rules and regulations resulting in serious violations 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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3