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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 09/19/2022
Date Signed: 09/19/2022 12:21:01 PM


Document Has Been Signed on 09/19/2022 12:21 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:ATKINSON, DIANEFACILITY TYPE:
740
ADDRESS:7610 ISABELLA WAYTELEPHONE:
(206) 676-5300
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:214CENSUS: 150DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Diane AtkinsonTIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility’s annual inspection to focus on infection control. LPA met with Resident Service Director (RSD), Richard Padilla and Executive Director, Diane Atkinson.

During visit, LPA toured the facility with RSD to include the assisted living section, dining rooms, kitchen, activity rooms, memory care, and exterior. All fire exit routes were free and clear of obstruction. All staff observed wearing a face mask. At 11:05 a.m., LPA and RSD observed multiple sharp gardening tools and toxins accessible in the community garden. Staff immediately secured the gardening tools and toxins.

The facility's temperature was maintained between 68 - 75 degrees Fahrenheit. LPA observed 2 days worth of perishables and 7 days worth of non-perishables.

LPA observed a designated entry point. Facility uses Accushield for symptom screening and temperature check for all visitors and staff. Hand sanitizer made available at entry and throughout the facility. Bathrooms supplied with hand washing sign, hygiene product, and paper supplies. LPA observed the facility's Personal Protective Equipment (PPE) supplies and PPE cart. Trash can observed with lid. Facility clean and disinfect multiple times daily and as needed. Staff are N95 fit tested. LPA reviewed the facility's procedures with RSD to include infection control training, isolation, testing, and monitoring. The following posters observed to include required mask, social distancing, symptoms of COVID, and cough etiquette.

A deficiency was cited per California Code of Regulations, Title 22.

This report was reviewed with Executive Director, Diane Atkinson 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: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
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 09/19/2022 12:21 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: 09/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by having multiple sharp gardening tools and toxins accessible in the commuity garden to persons with dementia which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2022
Plan of Correction
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Licensee immediately secured all the sharp gardening tools and toxins during visit. Licensee states to implement a locked storage for all gardening supplies going forward. Licensee will review section 87705 and submit a statement of understanding of the section to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
LIC809 (FAS) - (06/04)
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