435202806-12-6-2024-26-AS-KHOS-DC2PW5-20241217104011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202806
Report Date: 12/06/2024
Date Signed: 12/06/2024 11:50:50 AM

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
07/24/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20230724122911

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: 146	DATE:	12/06/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jocelyne Bailon		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Staff did not safeguard resident's personal belongings.
Staff did not ensure that resident's hygiene needs were met while in care.
Staff did not ensure that resident had clean linens while in care.
Staff did not follow safe sanitation practices.

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 Health Services Director, Jocelyne Bailon.

On 07/24/2023, the Department received the complaint. On 08/03/2023, the initial complaint investigation was conducted. Documented were obtained for this investigation to include the resident roster, staff schedule, resident (R1)’s progress notes, service plan, shower schedule, safeguard of personal property and valuables (LIC821), theft and loss policy, and facility training on infection control.

It was alleged that the facility staff did not safeguard resident (R1)’s dentures as it was observed missing by R1’s family member. It was alleged that R1’s missing dentures was not replaced after it was brought to the attention of the facility staff. Page 1 of 3.

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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20230724122911

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: 12/06/2024

NARRATIVE

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The review of R1’s service plan states that R1 has full dentures but refuses to wear the dentures.

4 staff members were interviewed. Based on staff interview, 4 out of 4 staff did not remember R1 using dentures. It was stated that R1 moved from Assisted Living to Memory Care and staff did not remember R1 moved into memory care with dentures.

Based on record review of R1’s safeguard of personal property and valuable form, there were no items to include the dentures that was entrusted to the facility. The word “waived” is written across the form and the form was signed and dated by R1’s responsible party on 03/17/2021.

It was alleged that the facility staff did not ensure that R1’s hygiene needs were met while in care as it was observed that R1 was filthy after not being bathed for a week. It was alleged that R1’s hygiene needs were not met because the facility was short staffed. The date of this encounter is unknown.

Based on record review, R1’s showers were scheduled twice a week and required staff hands on assistance.

4 staff members were interviewed. Based on staff interview, 4 out of 4 staff denied R1’s hygiene needs being neglected by the staff. Staff states that R1’s family did not bring up any concerns that R1 wasn’t showered for a week. Staff states the facility was short staffed around July 2023 but denied the shortage of staff reflecting on the shower schedule. Staff states the residents were still being provided their showers on their scheduled days. The review of the facility’s staffing schedule shows that there were at least 3 staff scheduled in memory care, in the AM and PM.

It was alleged that staff did not ensure R1 had clean linens while in care as there was a day where R1’s responsible party and R1’s social worker needed to change R1’s bedsheets because they were soiled. 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: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20230724122911

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: 12/06/2024

NARRATIVE

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The date of this encounter is unknown.

4 staff members were interviewed. Based on staff interview, 4 out of 4 staff were not able to recall a time where R1 had soiled linens. It was stated that if staff were to observe that a resident’s sheets are soiled, the staff would immediately change the sheets and put new ones.

It was alleged that staff did not follow safe sanitation practices as a staff who wore disposable gloves for cleaning was touching other surfaces and items with the same glove on. It was stated that when R1’s responsible party placed R1’s soiled items outside R1’s bedroom door for laundry service, the staff picked up the soiled linens with possibly the same disposable gloves. It was stated that the staff did not serve R1 any food. The reporting party did not indicate that the staff provided any care to the resident or other residents with the same gloves used during cleaning.

4 staff members were interviewed. Based on staff interview, it was stated that they spoke with the alleged staff who did not follow safe sanitation practices, and the staff denied the allegation. It was stated that facility staff are provided training on infection control. Staff state that they can use gloves when cleaning but they are trained to change out their gloves before they provide any care to the residents. It was stated that staff are trained to change their gloves after every resident when assisting them with ADL (activities of daily living) care. Based on record review, infection control training was completed on 05/25/2023.

The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation is 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 Health Services Director, Jocelyne Bailon and a copy of the report was provided. Page 3 of 3.

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

LIC9099 (FAS) - (06/04)

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