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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202806
Report Date: 12/19/2024
Date Signed: 12/19/2024 04:41:28 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
05/23/2024 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20240523113501
FACILITY NAME:MERRILL GARDENS AT GILROYFACILITY NUMBER:
435202806
ADMINISTRATOR:NELSON RODRIGUESFACILITY TYPE:
740
ADDRESS:7610 ISABELLA WAYTELEPHONE:
(206) 676-5300
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:214CENSUS: 139DATE:
12/19/2024
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Billy MitchellTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff did not ensure residents had adequate night supervision
Staff did not answer resident’s call buttons in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegations. LPA met with General Manager, Billy Mitchell.

On 05/23/2024, the Department received a complaint. On 05/29/2024, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include the staff schedule, LIC500, for May 2024, pendant logs, and 2 staff files.

It was alleged that the facility does not have adequate night supervision because on Sunday and Monday there is only one caregiver and one medtech scheduled to work the NOC shift. Page 1 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (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 6
Control Number 26-AS-20240523113501
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 it’s difficult for staff to respond to residents call buttons in a timely manner due to the low number of staff who work the night shift. It was stated that instead of the response times being between 5-10 minutes, it has increased to 20-30 minutes

On 05/29/2024, 3 residents were interviewed. Based on resident interview, 2 out of 3 residents states that the facility does not have enough night supervision. It was stated that there is only 2-night shift staff for the whole building.

4 staff members were interviewed throughout this investigation. Based on staff interview, 2 staff states there is not enough night supervision staff. 2 staff states there is only two staff who work the NOC shift. It was stated that there were some days where only one staff would work the NOC shift. S3 stated that there was a time before S3 was hired when there was only 1 NOC shift staff working in Prom and Plaza.

Based on record review, the NOC staffing schedule in May 2024, it shows only 1 caregiver scheduled in the Prom/Plaza (Assisted Living) section of the facility on Sunday and Mondays. Based on staff interview, the standard NOC staffing schedule should be 2 staff in the prom and plaza area.

Based on resident interview, 2 out of 3 residents states a negative experience with the facility’s pendant system. R1 states a time where he/she was sitting on the floor for about 45 minutes before a staff responded to his/her pendant call. R2 states that no one comes for about 45 minutes. R2 states in the morning, it takes about half an hour to an hour for staff to respond.

Based on review of R1’s pendant call logs, it shows that in May 2024 there were 88 calls that had a response time of 10 minutes and more. 33 out of 88 calls had over a 30-minute response time. 26 out of 88 calls had over a 15-minute response time between the hours of 10:00PM – 6:00AM. Page 2 of 3.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (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 6
Control Number 26-AS-20240523113501
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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Based on review of R2’s pendant calls logs, it shows that in May 2024 there were 55 calls that had a response time of 10 minutes or more. 16 out of 55 calls had over a 30-minute response time. R2 did not press the call button between the hours of 10PM – 6AM.

Based on interview with the General Manager, the expectations is for staff to respond to the residents call button within 15 minutes.

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. Deficiencies are 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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (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 6
Control Number 26-AS-20240523113501
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
87468.2(a)(4)
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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, … (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
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Licensee is currently scheduling 2 caregivers for Prom and Plaza during the NOC shift, which is the facility's standard ratio for NOC. Licensee will submit the staffing schedule for the NOC shift which shows their standard staffing ratio.
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Based on interview and record review, the licensee did not ensure there was enough staff scheduled in prom and plaza during the NOC shift in May 2024 and did not ensure staff responded to the resident’s call buttons within 15 minutes, which poses an immediate health, safety and personal rights risk to persons in care.
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Licensee will also provide an in-service training to staff regarding timely pendant call response times. Licensee will submit the in-service training to LPA Dolores via email by POC due date on 12/20/2024.
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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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (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)
Page: 4 of 6
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
05/23/2024 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20240523113501

FACILITY NAME:MERRILL GARDENS AT GILROYFACILITY NUMBER:
435202806
ADMINISTRATOR:NELSON RODRIGUESFACILITY TYPE:
740
ADDRESS:7610 ISABELLA WAYTELEPHONE:
(206) 676-5300
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:214CENSUS: DATE:
12/19/2024
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Billy MitchellTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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2
3
4
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9
Staff did not provide resident with bed sheets
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegations. LPA met with General Manager, Billy Mitchell.

On 05/23/2024, the Department received a complaint. On 05/29/2024, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include the staff schedule, LIC500, for May 2024, pendant logs, and 2 staff files.

It was alleged that staff left resident (R1) without bedsheets overnight as S1 was unable to lift R1. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (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: 5 of 6
Control Number 26-AS-20240523113501
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 06/12/2024, 3 residents were interviewed. Based on interview, 3 out of 3 residents stated the bedsheets are self-provided and staff assist with washing their bedsheets. 3 out of 3 residents denied being left in bed without bed sheets. Based on interview with R1, R1 denied being left in bed without bed sheets. R1 states that staff has changed his/her sheets in the middle of the night because he/she wet the bed, but staff did place another set of sheets on his/her bed. R1 states that some of the staff are not able to change his/her sheets in the middle of the night but R1 stated that staff always provided him/her with bed sheets.

On 06/12/2024, LPA Dolores observed R1’s bed had bedsheets.

A witness (W1) was interviewed. W1 stated that R1’s bed sheets were self-provided. W1 states a time where he/she observed R1’s bed was made but upon checking the bed, W1 observed R1’s bed sheets were stained with urine and blood. W1 thinks that the night staff might have left R1 in bed with the urine and blood-stained sheets because the staff was not able to lift R1. W1 denied observing R1 without bed sheets.

The Department has investigated the above allegation. Based on interview and observation the above allegation is unsubstantiated. An unsubstantiated finding indicated 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 General Manager, Billy Mitchell and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (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: 6 of 6