435202806-12-19-2024-26-AS-KHOS-DCJSWR-20250102131448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202806
Report Date: 12/19/2024
Date Signed: 12/19/2024 04:44:40 PM

Substantiated

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
02/26/2024 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20240226134837

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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Facility staff took resident belongings
Facility staff did not follow residents care plan

INVESTIGATION FINDINGS:

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

On 02/26/2024, the Department received the complaint. On 03/06/2024, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include 2 residents’ identification and emergency information, physician’s report, service plan, progress notes, safeguard of personal properties and valuables, facility’s policy and procedures on medication management, evaluation and service planning, and email correspondences.

It was alleged that the facility staff took resident (R1)’s 5 bottles of medications, two pill organizers, and multivitamins inside his/her room while R1 and R1’s spouse was not present in their room. Page 1 of 3.

Substantiated

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)

Page: 1 of 4

Control Number 26-AS-20240226134837

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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It was also alleged that staff did not follow R1’s care plan as R1’s care plan states he/she is not on medication management when staff removed the medications from R1’s bedroom.

1 staff member was interviewed regarding this investigation. This staff member was present and involved in removing R1’s medication from R1’s bedroom. Based on staff interview, R1 was not under medication management during the time of move-in and the General Manager at the time approved R1’s spouse to help administer R1’s medications. One day [specific date unknown], S1 was directed by the General Manager to remove R1’s medications from his/her room. The reason the medications needed to be removed was after the facility nurse determined R1 needed assistance with medication management after completing a 30-day medication evaluation after admission. However, the nurse did not provide and finalize the updated evaluation prior to removing the medications from R1’s bedroom.

S1 stated that prior to removing R1’s medications from his/her room, the staff did not notify R1 or R1’s spouse and/or family member that R1’s medications would be removed. S1 admitted this to be a mistake as they should have notified R1 and R1’s responsible parties prior to removing the medications. R1’s spouse became upset with staff, in which staff returned R1’s medications.

Based on record review, R1’s service plan upon admission dated 12/30/2023 indicated that R1 was independent and did not require assistance with medication administration. It’s indicated that R1 could self-manage his/her medications. R1’s service plan was updated in July 2024. Based on R1’s physician’s report from January 2024, it stated that R1 had mild cognitive impairment and was able to administer own prescription medication, able to administer own PRN medication and able to store own medications. The review of records does not show any incidents concerning R1’s medication compliance and safety by storing his/her own medication. There were also no records from R1’s physician regarding the change of R1’s capacity to store his/her own medications or other diagnosis which would deem unsafe if R1 would store his/her medications. 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: 12/19/2024

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)

Page: 2 of 4

Control Number 26-AS-20240226134837

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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The Department has investigated the above allegations. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegations are substantiated. A deficiency is being cited per California Code of Regulations, Title 22. See LIC9099-D.

This report was reviewed with General Manager, Billy Mitchell and a copy of the report and appeal rights were 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: 12/19/2024

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)

Page: 3 of 4

Control Number 26-AS-20240226134837

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/20/2024 Section Cited CCR 87468.1(a)(8)	1 2 3 4 5 6 7	(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will provide an in-service training with staff regarding the appropriate steps for when a resident is determined to need medication management, to include proper communication with the resident
	8 9 10 11 12 13 14	Based on interview, record review and observation the licensee did ensure to comply with the section cited above by not informing R1 and R1’s authorized representatives of the need to remove R1’s medications from his/her room prior to removing the medications, despite R1’s care plan not requiring medication management which poses an immediate health, safety and personal rights risk to persons in care.	8 9 10 11 12 13 14	and resident's authorized representatives. Licensee will submit the in-service training document to LPA Dolores via email by POC due date of 12/20/2024.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC9099 (FAS) - (06/04)

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