435202806-12-19-2024-26-AS-KHOS-DCJT36-20250102132148

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202806
Report Date: 12/19/2024
Date Signed: 12/19/2024 04:43:37 PM

Unfounded

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
03/28/2024 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20240328152505

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: 139	DATE:	12/19/2024
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Billy Mitchell		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff did not follow resident’s care plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding regarding the above allegation. LPA met with General Manager, Billy Mitchell.

On 03/28/2024, the Department received the complaint. On 04/05/2024, the initial complaint investigation was opened. The following documents were obtained to include resident (R1)’s physician’s report, service plans, progress notes, incident reports, resident roster, and staff schedule.

On 03/01/2024, resident (R1) sustained an unwitnessed fall and reported that it had been about 2 hours before anyone came to check in on R1. It was alleged that the staff did not follow R1’s care plan of checking in on R1 every hour. Upon R1’s visit to the hospital on 03/04/2024, it was found that R1 sustained an injury to the head, leg swelling, and back pain. Page 1 of 2.

Unfounded

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: 12/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

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-20240328152505

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: 12/19/2024

NARRATIVE

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On 04/05/2024, 5 staff members were interviewed. Based on staff interview, it was stated that staff check in on R1 at least 2 times per day for medications, however caregivers check in on R1 about 2 or 3 times more per shift. It was stated that there were no incidents reported for R1 on 03/01/2024. The number of times staff check in on R1, was depending on the staff. S2 stated to check in on R1 about 3 – 5 times per his/her shift. S3 states to check in on R1 at least 4 times per his/her shift. S4 states to check in on R1 about 4-5 times per his/her shift.

Based on record review, on 03/01/2024, there were no progress notes written by staff on this day. On 03/02/2024, it was noted that R1 requested for pain reliver medication due to pain. From 03/02/2024 – 03/04/2024, R1 was on alert charting due to a change of condition and was being monitored for his/her pain. On 03/03/2024, staff mentioned concern that R1’s pain could be a cause of a fall. On 03/04/2024, R1 was taken to the hospital by his/her family member where R1 was seen for a swollen ankle.

The review of records show that R1 is a high potential for falls but does not require assistance with ambulation, mobility, escorting, and transferring. On R1’s service plan, it states that R1’s family member has been evaluated by the community to be at risk for injury which may cause permanent disability or be life threatening. Interventions were put in place for R1’s safety, however, based on record review there was no indication on R1’s service plan that staff were required to check in on R1 every hour.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded, meaning the allegation is false, could not have happened, and/or is without a reasonable basis. 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.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC9099 (FAS) - (06/04)

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