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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 02/20/2025
Date Signed: 02/20/2025 12:08:04 PM

Document Has Been Signed on 02/20/2025 12:08 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:		BILLY MITCHELLFACILITY TYPE:
740
ADDRESS:7610 ISABELLA WAYTELEPHONE:
(206) 676-5300
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 214TOTAL ENROLLED CHILDREN: 0CENSUS: 141DATE:
02/20/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Billy MitchellTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager, Billy Mitchell. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024.

During visit, LPA toured the facility with staff to include garden house (aka memory care), plaza, common areas, and courtyard areas. During the tour, LPA observed 11 staff members who are fingerprint cleared and associated to the facility.

In Garden House, LPA randomly entered into rooms 125A, 124, 122A, 120, and 113 with the Garden House Director. All sharp objects, chemicals, disinfectants, and garden supplies observed secured in garden house. LPA observed 1 out of the 5 rooms had hygiene products accessible, however, based on the resident's physician's report the resident is not at risk if allowed direct access to these items. LPA observed the resident's room door was closed.

In Plaza, LPA randomly entered into rooms 210 and 202 with the Health Services Director. LPA observed 1 out of 2 resident rooms (R1) contained chemicals/disinfectants to include laundry detergent and dish soap accessible in the cabinet underneath the kitchen sink. Based on review of this resident's (R1) file, the resident is diagnosed with dementia and should not have access to chemicals/disinfectant items per the signed physician's communication sheet. HSD removed the items immediately and informed the resident. Page 1 of 2.
Jackie JinTELEPHONE: (714) 319-3786
Christine KabaritiTELEPHONE: (408) 324-2112
DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/20/2025
NARRATIVE
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Based on the non-compliance plan, training was scheduled to be completed by a certain date for reporting requirements; change of condition and observations of decline in condition or ability; personal rights of a resident; reappraisals; and care of persons with dementia as it pertains to toxic substance and sharp objects. LPA observed all training topics stated on the non-compliance plan was completed on July 18, 2024. Staff were also provided in-service training on personal rights in December 2024. The training document contains the topic, date, name and signatures of the participants. LPA advised the GM to ensure all staff are provided annual training on these specific topics per the non-compliance plan.

5 random resident files were reviewed. The files reviewed contained a signed personal rights form, physician’s report, and a signed up-to-date appraisal/needs and services plan.

5 random staff files were reviewed. 5 staff are associated to the facility and fingerprint cleared. LPA Kabariti advised to ensure all new staff review and receive instruction regarding resident rights upon hire and the training must be documented in the staff’s file.
LPA advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation.

GM was reminded of the discussion on June 13, 2024 of the facility being under frequent monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. 

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with General Manager, Billy Mitchell and Health Services Director, Jocelyne Bailon and a copy of the report and appeal rights was provided.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine KabaritiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/20/2025 12:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2025
Section Cited
CCR
87309(a)

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(a) ... the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, ... and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.This requirement is not met as evidenced by:
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Licensee immediately removed the toxic items from resident (R1)'s room. Licensee will submit an in-service training for all staff regarding appropirate chemical safety for residents with dementia.
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Based on record review, interview and observation the licensee did not ensure to keep toxic items inaccessible to resident (R1) who is diagnosed with dementia and should not have access to cleaning solutions and toxins per the physician, which posed an immediate health, safety, and personal rights risk to persons in care.
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Licensee will submit the in-service training document to LPA Kabariti via email by POC due date.

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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.
Jackie JinTELEPHONE: (714) 319-3786
Christine KabaritiTELEPHONE: (408) 324-2112

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025

LIC809 (FAS) - (06/04)
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