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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 12:01:57 PM

Document Has Been Signed on 12/06/2024 12:01 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:
12:05 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Health Services Director, Jocelyne Bailon. The purpose of the visit was to follow-up on a physical abuse incident that occurred at the facility the night of 12/02/2024. On 12/03/2024, the Department was informed of an incident that occurred between staff (S1) and resident (R1). On 12/03/2024, the community was made aware that R1 was treated in an aggressive manner by S1 the night of 12/02/2024. The incident was captured on the facility's fall detection video system.

After the community was made of the incident, S1 was escorted out of the building on 12/03/2024. S1’s employment was terminated on 12/04/2024. The facility also conducted an internal investigation with all the staff involved and who have witnessed the fall detection video footage. On 12/04/2024 and 12/05/2024, the facility conducted an in-service training with all staff (AM/PM/NOC) to include topics of understanding the importance of “see something say something”; mandated reporters; the steps to take to ensure residents safety and well-being; and understanding resident rights. HSD states the training also included proper intervention and techniques for redirection, de-escalation, and dementia. Documents were obtained to include the in-service training sheet/materials and 4 staff member’s job application. A copy of the fall detection video was provided to LPA Dolores via a USB stick.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Health Services Director, Jocelyne Bailon and a copy of the report was 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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