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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202806
Report Date: 01/16/2024
Date Signed: 06/24/2024 11:10:07 AM

Unfounded


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
04/04/2022 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20220404161647
FACILITY NAME:MERRILL GARDENS AT GILROYFACILITY NUMBER:
435202806
ADMINISTRATOR:ATKINSON, DIANEFACILITY TYPE:
740
ADDRESS:7610 ISABELLA WAYTELEPHONE:
(206) 676-5300
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:214CENSUS: 145DATE:
01/16/2024
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:KIM GOLDENTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Facility allowing unauthorizied visitors
INVESTIGATION FINDINGS:
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THIS IS AN AMENDED REPORT FROM 01/16/2024. Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegation. LPA met with Executive Director, Kim Golden.

On 04/04/2022, the Department received a complaint alleging that the facility did not stop resident (R1)’s relatives from visiting R1, therefore, allowing an unauthorized visitor. It was alleged the incident happened around January 2021 – June 2021. On 04/13/2022, the initial complaint investigation was conducted.

The following documents were obtained to include resident (R1)’s residency and service agreement, physician’s report, appraisal/needs and services plan, power of attorney (POA) documents, and progress notes. SEE LIC9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
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 2
Control Number 26-AS-20220404161647
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: 01/16/2024
NARRATIVE
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On 04/13/2022, the Administrator was interviewed. Based on interview, the facility did not have any current residents who have restraining orders or any unauthorized visitations. It was stated the residents have a right to see who they want and can have visitors if they consent to it unless there is a restraining order. It was stated that if a resident’s POA does not want a resident to see a certain visitor, the resident still has their right to consent to the visitation.

Based on interview, R1’s POA did not want anyone to see R1. It was stated that R1 always wants to see his/her relative and can see his/her realize if he/she consents to the visitation. Staff (S2) stated R1's responsible party verbally stated they did not want R1's relative to visit, however, R1 always consented to seeing R1's relative.

Based on record review, there is no documentation that R1 had any restraining orders nor was the facility provided a list of unauthorized visitors from the resident and/or resident's responsible party.

Based on review of R1's POA (power of attorney) documentation, there is no documentation that allows R1's POA to restrict visitations.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded meaning the allegation is 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 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: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
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