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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 06/24/2024
Date Signed: 06/24/2024 11:09:33 AM


Document Has Been Signed on 06/24/2024 11:09 AM - 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:
06/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:KIM GOLDENTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Executive Director (ED) Kim Golden.

During visit, a complaint report for complaint control number: 26-AS-20220404161647 was amended. The amended report was reviewed and handed to the ED.

On 06/12/2024, the facility was issued a civil penalty for a staff member working in the facility without a criminal background check clearance. On 06/12/2024, the wrong civil penalty assessment form was generated.

During today visit, the correct civil penalty form (LIC421BG) was reviewed and signed by the ED. LPA obtained the hard copy of the LIC421BG. ED obtained a copy of the signed LIC421BG.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director Kim Golden and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024
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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