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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 09/07/2021
Date Signed: 09/08/2021 08:16:23 AM

Document Has Been Signed on 09/08/2021 08:16 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
CCLD Regional Office, 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: 142DATE:
09/07/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Diane AtkinsonTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Christine Dolores and Licensing Program Manager (LPM) Jackie Jin conducted an unannounced pre-licensing continuation visit from 8/20/2021. LPA and LPM met with Administrator, Diane Atkinson.

During today's visit, LPA and LPM observed the following posters: personal rights, if you see something say something, ombudsmen, and resident right to counsel posted. Resident Admission Agreement and Death and Loss policy is available for the public to review upon request.

LPA and LPM reviewed 13 resident files and 13 staff files. Facility staff are fingerprint cleared and associated to the facility. Resident files all consist of Admission Agreement, Medical Assessment with TB Information, Consent Forms, Care Plans, Safeguard for Personal Properties and Valuables, and Personal Rights. Staff files all consist of Personal Record, Health Screening with TB Information, and Criminal Record Statement.

Component III is being waived because applicant has been a facility administrator since 11/1986.

No issues noted during this pre-licensing inspection.

LPA and LPM observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Diane Atkinson, Administrator and a copy of this report provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2021
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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