435202806-9-19-2024-26-AS-JJIN-D9VUGY-20241009153505

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202806
Report Date: 09/19/2024
Date Signed: 09/19/2024 04:53:43 PM

Substantiated

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
06/24/2022 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20220624162710

FACILITY NAME:	MERRILL GARDENS AT GILROY		FACILITY NUMBER:	435202806
ADMINISTRATOR:	ATKINSON, DIANE		FACILITY TYPE:	740
ADDRESS:	7610 ISABELLA WAY		TELEPHONE:	(206) 676-5300
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	214	CENSUS: 140	DATE:	09/19/2024
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Billy Mitchell		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff member roughly handled resident in care
Facility did not inform resident's family of change in resident's condition

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Christine Dolores and Marcella Tarin arrived unannounced to deliver the findings of the above allegations. LPAs met with General Manager, Billy Mitchell.

On 06/24/2022, the Department received the complaint. On 07/01/2022, the initial complaint investigation was conducted.

The following documents were obtained for this investigation: resident (R1)’s physician’s report, service plan, communication log, medication administration record, identification and emergency contact information, incident report, staff schedule, memory care resident roster, and police report. PAGE 1 OF 3.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 26-AS-20220624162710

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: 09/19/2024

NARRATIVE

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It was alleged that a staff member (S1) had roughly handled resident (R1) in care during the night of 06/13/2022 approximately around midnight. It was alleged that (S1) was upset that R1 was still awake around midnight and aggressively grabbed R1 from behind and pulled R1 up from his/her wheelchair.

On 07/01/2022, 5 staff members were interviewed. Based on interview, S3 stated to be made aware of the incident between S1 and R1, on 06/15/2022, 2 days after the incident. S3 was notified by another staff (S2) of the observation between S1 and R1 the night of 06/13/2022. S3 stated that S2 gave R1 popcorn shortly after R1 had a fall, when S1 came into the TV room and “yanked” R1 up from his/her wheelchair, wrapped R1 under his/her shoulder saying it was time for bed. S2 attempted to defend R1 but S1 still continued to take R1 to bed.

Based on review of the police records, a statement was taken from S2, who witnessed the incident. S2 stated to be in the dining room eating popcorn with R1, when S1 entered the room very upset that R1 was still up as it was 0030 hours. S1 approached R1 was behind and grabbed R1. S1’s arms were underneath R1 when S1 lifted R1 in an aggressive manger. S1 then forced R1 back and down into his/her wheelchair.

Based on review of the police records, a statement was taken from R1. It was reported that R1 was in the dining room of the facility with S2 eating popcorn, when S1 entered the room upset and yelling at R1 for staying up. R1 reported that S1 approached him/her from behind and grabbed the victim from underneath the arms, lifted R1 up with S1’s hands across R1’s chest, inches below his/her throat and squeezed him/her. R1 reported that S1 had grabbed his/her right ring finger and attempted to fold it back. S1 wheeled R1 into his/her room and S1 slammed his/her up against the wall and put him/her to bed.
Based on review of the police records, injuries were noted on 06/17/2022. R1 was observed with some bruising underneath both the left and right arms. Bruising was also noted on R1’s right forearm and right ring finger.

PAGE 2 OF 3.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20220624162710

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: 09/19/2024

NARRATIVE

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After the incident, it was alleged that the facility did not informed R1’s family of a change in condition as R1 complained of pain and couldn’t move his/her arms and shoulders. It was alleged that the family was only notified of a fall that took place on 06/13/2022, and not the aggressiveness or pain until Friday, 06/17/2022 when bruises were discovered under R1’s arms.

Based on staff interview, S3 stated that on 06/14/2022, 06/15/2022, and 06/16/2022 R1 complained of shoulder pain and requested for a PRN. S3 administered the PRN medication and monitored R1 for effectiveness of the PRN. On 06/14/2022, S3 did not notice any discoloration or bruising on R1 and informed his/her supervisor (S4) that R1 was complaining of shoulder pain.

Based on interview with S4, S4 was made aware of incident at about 5:00PM on 06/15/2022. On 06/15/2022, S4 assessed R1 and observed R1 complained of pain on the left shoulder. S4 stated that R1 was complaining of so much pain that they couldn’t get R1’s shirt up to observe. S4 faxed the doctor. On 06/16/2022, S4 called the family and stated to have notified the family of R1’s shoulder pain and headache and suggested to R1’s responsible party to take R1 to the doctor to make sure.

Based on review of R1’s records, it was indicated that on 06/16/2022 staff spoke with R1’s responsible party that R1 hasn’t been sleeping well at night. There was no note that staff informed R1’s responsible party of any complaints of pain starting from 06/14/2022, when R1 first complained of shoulder pain.

Based on record review and interview, S1 was moved to assisted living and no longer assigned to the memory care unit.

The Department has investigated the above allegations. Based on interview and record review the preponderance of evidence standard has been met, therefore, the above allegations are substantiated. Deficiencies were cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with General Manager, Billy Mitchell and Health Services Director, Jocelyn Bailon and a copy of the report and appeal rights were provided. PAGE 3 OF 3.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20220624162710

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/20/2024 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will conduct an in-service training on the section cited. Licensee will submit the in-service training record to LPA Dolores via email by POC due date of 09/20/2024.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not ensure resident (R1) was free from abuse by staff (S1) who handled R1 roughly on the night of 06/13/2022 which poses an immediate, health, safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
Type A 09/20/2024 Section Cited ILS 87463(b)	1 2 3 4 5 6 7	(b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will conduct an in-service training on the section cited. Licensee will submit the in-service training record to LPA Dolores via email by POC due date of 09/20/2024.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not ensure to immediately bring to the attention of resident (R1)’s family or responsible party of R1’s shoulder pain which poses an immediate health, safety and personal rights risks to persons in care.	8 9 10 11 12 13 14

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 Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
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

LIC9099 (FAS) - (06/04)

Page: 4 of 4