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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 12/06/2024
Date Signed: 12/06/2024 12:18:52 PM

Document Has Been Signed on 12/06/2024 12:18 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: 146DATE:
12/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Jocelyne BailonTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a follow-up case management – incident visit that was initiated on 05/29/2024. LPA met with Health Services Director, Jocelyne Bailon.

On 05/25/2024, resident (R1) passed away at the facility and the cause of death was an accident. R1 had ligature strangulation in the setting of ethanol use. Based on R1’s evaluation report dated 11/30/2023, R1 had a history of substance use which may cause some interpersonal and/or health problems but does not significantly impair overall independent functioning. However, staff still had concerns about R1’s alcohol consumption and overall safety after drinking alcohol. Based on R1’s progress notes, R1 had multiple fall incidents from 2021 – 2024 resulting in injuries. Staff interviewed were aware that R1 was a fall risk, had multiple fall incidents and liked to drink alcohol.

The review of R1’s assessment shows R1 was last re-assessed on 11/30/2023, even though R1 continued to be a fall risk and had multiple falls resulting in injuries after 11/30/2023. There was no reassessment completed after 11/30/2024.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty of $1000 is being assessed today for a repeat violation within 12 months. See LIC421IM. Failure to correct the deficiency may result in additional civil penalties. An additional Civil Penalty for a violation resulting in serious bodily injury of a resident is pending review.

This report was reviewed with Health Services Director, Jocelyne Bailon and a copy of the report along with the appeal rights were provided.
Sarah YipTELEPHONE: (408) 324-2131
Christine DoloresTELEPHONE: (408) 334-8552
DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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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Document Has Been Signed on 12/06/2024 12:18 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/06/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(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: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) … This requirement is not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 12/07/2024
Plan of Correction
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Licensee states they will reassess residents upon a change of condition immediately. Licensee will submit a statement of understanding of the section cited and the plan going forward, to LPA Dolores via email by POC due date (12/07/24).
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sarah YipTELEPHONE: (408) 324-2131
Christine DoloresTELEPHONE: (408) 334-8552

DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024

LIC809 (FAS) - (06/04)
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