435202806-9-19-2024-26-AS-MTAN-D9A24L-20240919170407

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 09/19/2024
Date Signed: 09/19/2024 05:04:49 PM

Document Has Been Signed on 09/19/2024 05:04 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 GILROY		FACILITY NUMBER:	435202806
ADMINISTRATOR:	KIM GOLDEN		FACILITY TYPE:	740
ADDRESS:	7610 ISABELLA WAY		TELEPHONE:	(206) 676-5300
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	214	CENSUS:	DATE:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	General Manager, Billy Mitchell		TIME COMPLETED:	05:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Marcella Tarin and LPA Christine Delores conducted an unannounced annual inspection visit at 9:45AM and met with General Manager (GM) Billy Mitchell and Health Services Director, Jocelyn Bailon. LPAs toured the facility inside and out with the General Manager to include the living room, dining room, kitchen, resident bedrooms, bathrooms, and exterior. Facility temperature maintained between 70 to 75 degrees F. Facility staff are fingerprint cleared and associated to facility. All emergency exits were observed to be clear of obstruction. LPAs toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature maintained at 35 degrees F and freezer maintained at -5 degrees F. The exterior of the facility was also inspected. No toxins, chemicals or items that can pose a danger to residents observed. LPA Tarin toured 7 resident bedrooms. 7 out of 7 resident bedrooms had functioning lights, storage space for personal belongings, clean bedding, a chair, lamp and dresser/table. LPA measured hot water temperature, range of 106.7 to 115.7 degrees F for 7 out of 7 resident bathrooms. The facility was equipped with smoke and carbon monoxide detectors. Fire extinguishers were last serviced on 6/30/2024. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake drill log was reviewed and drills are being conducted quarterly. The last fire drill was conducted on 6/30/2024. Facility has emergency disaster plan. LPA reviewed 7 residents Centrally Stored Medication and Destruction Records (CSMDR). LPA observed 7 out of 7 CSMDRs are complete with all medications accounted and documented. LPA observed the medication storage area was locked and inaccessible to residents in care. Please see LIC 809-C.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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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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: 09/19/2024

NARRATIVE

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LPA reviewed 5 out of 5 resident records. LPA observed 5 out of 5 resident records as complete to include a medical assessment, TB result, updated appraisal/needs and services plan, identification and emergency contact information, personal rights, and consent forms.

LPA reviewed 6 out of 6 staff records. LPA observed 4 out of 6 records as complete to include fingerprint clearance, health screening, TB result, and personnel record. Staff (S1) and (S4) records were observed as incomplete. S1 file was not available for review by LPA. GM states corporate has the file and does not have the physical file in the facility. S1 does not have a health screening and TB result. GM states a plan to obtain a health screening and TB result. S4's file does not contain a health screening and TB result. GM states they have requested the health screening and TB result and are awaiting the documentation.

6 out of 6 staff records did not contain documentation for annual training. GM states he has the training records on file in an email and will email staff training records to LPA Tarin by morning of 9/20/2024. LPAs advised GM that all personnel records must be maintained at the facility and available for review by the licensing agency. During visit LPA obtained GM's administrator certificate and resume.

Deficiencies were cited today per California Code of Regulations, Title 22. See LIC809-. Exit interview was conducted with GM. This report was provided to GM and appeals rights were provided.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2024 05:04 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: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and observation, licensee did ensure staff (S1) and (S4) health screening and TB result was not on file which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 09/26/2024
	Plan of Correction
1 2 3 4	Licensee will submit a plan of correction to ensure (S1) and (S4) obtain health screening and TB result via email to LPA Tarin by POC due date 9/26/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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