435202806-10-7-2024-26-AS-KHOS-DA5HQ9-20241017062335

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202806
Report Date: 10/07/2024
Date Signed: 10/07/2024 03:16:01 PM

Unsubstantiated

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
07/14/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20230714114133

FACILITY NAME:	MERRILL GARDENS AT GILROY		FACILITY NUMBER:	435202806
ADMINISTRATOR:	NELSON RODRIGUES		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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Staff pureed food without authorization.
Staff not accommodating resident diet needs.

INVESTIGATION FINDINGS:

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

On 07/14/2023, the Department received the complaint. On 07/21/2023, the initial complaint investigation was conducted.

Documents were obtained to include facility’s roster from June – July 2023, resident (R1)’s physician’s report, physician’s orders, special diet form, physician communication fax, medical records, medication list, progress notes, weight analysis, service agreement from April – May 2023, and medication administrator record (MAR) from April – June 2023. 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)

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Control Number 26-AS-20230714114133

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 pureed resident (R1)’s food without authorization from R1’s responsible party. On 07/21/2023, 2 staff members were interviewed. Based on staff interview, S2 states that when R1 returned from his/her doctor’s appointment, R1’s responsible party provided the paper that states there was a change in diet to puree from R1’s doctor visit sometime in April 2023. S2 states that R1’s responsible party knew there was a change in diet because R1’s responsible party provided the facility with the diet order. S2 states R1’s hospice team was also informed of the diet change. Based on record review, R1’s physician signed a “diet order and dietary communication” form on 04/21/2023 for a puree diet.

It was alleged that the facility staff are not accommodating to R1’s diet needs by not providing R1 with a nutritional beverage.

The review of records show that R1’s physician’s report dated in March 2023 states a special diet for a nutritional beverage. On 07/21/2023, 2 staff members were interviewed. Based on staff interview, S2 states that they did not follow-up with R1’s physician in March to obtain the physician’s order for the nutritional beverage. S2 states despite the physician’s report in March 2023 stating R1 has a special diet for a nutritional beverage, the facility still requires an actual order from the physician. S2 states that since they did not have an actual physician’s order for the nutritional beverage, they were unable to provide the beverage to R1. S2 states they received an order in June 2023.

The Department has investigated the above allegations. Based on interview and record review the above allegations are unsubstantiated. An unsubstantiated finding indicated that although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. However, a case management visit was conducted on 10/07/2024 due to a violation 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 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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