435202806-10-7-2024-26-AS-KHOS-DA5HCT-20241017060514

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202806
Report Date: 10/07/2024
Date Signed: 10/07/2024 03:13:25 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
12/15/2022 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20221215152806

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: 141	DATE:	10/07/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Billy Mitchell		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Facility staff are not reappraising resident after falls
Resident sustained injuries due to multiple falls while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegations. LPA met with General Manager, Billy Mitchell and Resident Care Director, Jocelyne Bailon Solache.

On 12/15/2022, the Department received a complaint regarding the above allegations. On 12/22/2022, the initial complaint investigation was conducted.

The following documents were obtained to include resident (R1)’s service plans, physician’s report, preplacement appraisal, functional capabilities assessment, progress notes, admission agreement and emergency contact information. 3 other resident records were obtained. 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: 10/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024

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 6

Control Number 26-AS-20221215152806

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: 10/07/2024

NARRATIVE

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It was alleged that the facility staff are not reappraising resident (R1) after falls resulting in resident sustaining injuries due to multiple falls.

R1’s service plans from year 2021 - 2022 were reviewed.

The review of records shows that on 04/07/2022, R1 was re-evaluated, and the fall potential section was updated from a low potential to a moderate potential for falls. The service plan included an action plan to check on R1 during med passes, meals and activities, provide night lights, arrange items within reach, slip mats in bathtub/shower, showers are draining properly, change heights of items to accommodate resident, remove trip hazards, check carpet/floor for intact surfaces, rearrange furniture if appropriate, emergency devices working and within reach, and room clutter.

On 04/29/2022, R1 was re-evaluated, and the fall potential section was updated from moderate potential to high potential for falls. There were no action plans indicated on the service plan. The re-evaluation was based on a fall that was noted in R1’s record on 04/30/2022.

Between 04/30/2022 – 09/08/2022, R1 was noted to have 8 falls (05/29, 06/24, 07/03, 07/05, 07/06, 08/08, 08/11, and 08/28).

On 09/09/2022, R1 was re-evaluated, and the service plan was updated to still indicate a high potential for falls. The service plan included an action plan to include removing trip hazards and room clutter.

Between 09/10/2022 – 11/22/2022, R1 was noted to have 14 falls (09/23, 09/24, 09/25, 10/01, 10/05, 10/07 (R1 noted to have 2 falls this day), 10/10, 10/31, 11/03, 11/05, 11/07, 11/08, 11/21).

On 11/23/2022, R1 was re-evaluated, and the service plan was updated to still indicate a high potential for falls. The service plan included an action plan to use walker, arrange items to be within reach, and remove trip hazards. 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: 10/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 26-AS-20221215152806

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: 10/07/2024

NARRATIVE

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The review of records show that R1 sustained injuries after falls on 08/28/2022 and 11/05/2022. On 08/28, R1 was observed to sustain a bump on his/her left forehead with redness. 911 was called and resident was not sent out after further assessment and discussion with family. On 11/05, R1 was sent to the hospital for a fall and unresponsiveness. Resident returned to the facility with the left forehead and cheeks swollen. On 11/06, resident was seen with a contusion on the right facial area post fall. On 12/12/2022, a witness observed resident was walking in the hallway without a walker with a big bump on the left forehead area. R1 denied a fall. R1 was transferred to the hospital and returned the same day with new medication.

Based on record review, the facility did not re-evaluate and update R1’s service plan after falls on 05/29, 06/24, 07/03, 07/05, 07/06, 08/08, 08/11, 09/23, 09/24, 09/25, 10/01, 10/05, 10/07, 10/10, 10/31, 11/03, 11/05, 11/07, 11/08, and 12/12.

The Department has investigated the above allegations. Based on record review and observation the preponderance of evidence standard has been met, therefore, the above allegations are substantiated. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D. A case management visit was conducted on 10/07/2024 due to violations observed during the investigation. See LIC809 on 10/07/2024.

This report was reviewed with General Manager, Billy Mitchell and a copy of the report and appeal rights were provided.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 26-AS-20221215152806

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: 10/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/08/2024 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a statement of understanding of the section cited (87463(a)) to LPA Dolores via email by POC due date of 10/08/2024.
	8 9 10 11 12 13 14	Based on record review and observation, the licensee did not ensure resident (R1) was re-evaluated and R1’s service plans were updated after falls resulting in the resident sustaining injuries due to the falls which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 10/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6

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
12/15/2022 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20221215152806

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:	DATE:	10/07/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Billy Mitchell		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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9

Lack of supervision resulting in resident sustaining multiple falls

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegations. LPA met with General Manager Billy Mitchell.

On 12/15/2022, the Department received a complaint regarding the above allegations. On 12/22/2022, the initial complaint investigation was conducted.

The following documents were obtained to include resident (R1)’s service plans, physician’s report, preplacement appraisal, functional capabilities assessment, progress notes, admission agreement and emergency contact information. 3 other resident records were obtained. PAGE 1.

Unsubstantiated

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: 10/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 26-AS-20221215152806

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: 10/07/2024

NARRATIVE

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It was alleged that resident (R1) sustained multiple falls due to the lack of supervision from facility staff.

Based on record review, R1 sustained multiple falls between April 2022 – December 2022. The falls were noted by staff in R1’s records to either be witnessed or unwitnessed falls. R1 sustained majority of the falls in his/her bedroom.

R1’s service plans on 04/07/2022, 04/29/2022, and 09/09/2022 R1 did not require staff assistance with mobility, ambulation or escorting.

R1’s service on 11/23/2022, indicated that R1 may require escorts with or without the use of assistive devices to and from meals, activities and/or common areas and the plan for staff to escort R1 with his/her walker to meals and activities due to being high fall risk.

On 11/05/2022, staff recommend a 24/7 companion due to frequent falls to R1’s responsible party. There is no indication that the 24/7 companion was started.

R1’s signed admission agreement states that the community is not designed to provide twenty-four-hour care. It’s stated that resident may remain in the community as long as the care needs and level of functioning are consistent with those of other residents and with the level of staffing and facilities offered in the community.

The Department has investigated the above allegation. Based on record review and observation, the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024

LIC9099 (FAS) - (06/04)

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