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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 10/29/2024
Date Signed: 10/29/2024 12:11:59 PM

Document Has Been Signed on 10/29/2024 12:11 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/
DIRECTOR:		KIM GOLDENFACILITY TYPE:
740
ADDRESS:7610 ISABELLA WAYTELEPHONE:
(206) 676-5300
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 214TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
10/29/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Billy MitchellTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager, Billy Mitchell.

The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024.

During visit, LPA toured the facility with GM to include garden house, assisted living, common areas, and courtyard areas. During the tour, LPA observed 9 staff members who are fingerprint cleared and associated to the facility. All sharp objects, chemicals, disinfectants, and garden supplies observed secured.

Based on the non-compliance plan, training was scheduled to be completed by a certain date for reporting requirements; change of condition and observations of decline in condition or ability; personal rights of a resident; reappraisals; and care of persons with dementia as it pertains to toxic substance and sharp objects. LPA observed all training topics stated on the non-compliance plan was completed by the expected dates. The training document contains the topic, date, name and signatures of the participants. GM states a plan to complete the training bi-annually.

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Sarah YipTELEPHONE: (408) 324-2131
Christine DoloresTELEPHONE: (408) 334-8552
DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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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
VISIT DATE: 10/29/2024
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5 resident files were reviewed. The files reviewed contained a signed personal rights form, physician’s report, and a signed up-to-date appraisal/needs and services plan.

5 staff files were reviewed. 5 staff are associated to the facility and fingerprint cleared. 5 staff are provided training on personal rights as of 10/29/2024. LPA Dolores advised to ensure all new staff review and receive instruction regarding resident rights upon hire and the training must be documented in the staff’s file.

LPA Dolores advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation.

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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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