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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 07/17/2025
Date Signed: 07/17/2025 04:04:40 PM

Document Has Been Signed on 07/17/2025 04:04 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: 214CENSUS: DATE:
07/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Billy MitchellTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. LPA met with General Manager (GM) Billy Mitchell.

The purpose of the visit was to follow-up on two incidents that was reported to the Department on 07/14/2025 and 07/17/2025.

On 07/14/2025, the Department was notified of alleged abuse between resident (R1) and R1’s private caregiver. It was stated that on 07/14/2025 around 1:00am, R1 pulled his/her pull cord and when staff responded R1 reported that he/she felt dizzy because R1’s private caregiver hit him/her in the head. Staff immediately contacted 911 and assessed the resident. There were no visible injuries such as bruising, redness, scratches, or marks on R1’s skin. The police arrived and R1 did not know why the police was there. The facility reported the incident to R1’s responsible party and felt R1 wasn’t in the right state of mind. Based on interview and record review, R1 has mild cognitive impairment and history of confusion upon waking up. R1’s family continued to keep services from the same private caregiver. Staff stated the resident has shown no indications of abuse. R1's physician's report, service plan and progress notes were obtained.

On 07/17/2025, the Department was notified of a medication error that occurred during the morning shift of 07/17/2025. It was reported that the MedTech in training (S1) administered resident (R2)’s medication to resident (R3). See LIC809-C for additional information.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/17/2025
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S1 was shadowing another MedTech (S2) on the floor. During the medication pass, S1 and S2 did not reconfirm the resident's medication prior to administering it. When S1 and S2 went to administer R2’s medication, the staff noticed they only had R3’s medication cup and then realized that R3 was given R2’s medication. R3 already left the community with family once the medication error was found. R3’s family and physician was immediately informed. The facility staff advised R3's authorized representative to seek medication attention, however it was stated that R3 was doing well. It was stated R3's family will monitor R3 during their outing and take action when needed.

The facility plans to remove both MedTechs from the floor. Both MedTechs will be required to complete the medication training courses again prior to working on the floor. The Licensee will also provide training for the MedTech trainers regarding medication pass oversight between the trainer and trainee.

The review of the facility’s compliance history showed another medication error of a similar incident occurred on 02/25/2025. The incident was reported to the Department on the same day. On 02/27/2025, LPA Kabariti followed up with the incident via phone call and it was stated that R1 was administered R2’s medication on accident by a MedTech in training (S3). S3 was shadowing MedTech (S4). S3 grabbed the wrong medication cup and did not reconfirm the medication prior to administering it to R1. R1 was taken to the hospital for monitoring and returned to the facility on the same day. Based on interview and record review, there were not adverse reactions from the medication error. After the incident, the facility removed both MedTechs from the floor and were required to complete re-training on medications. Based on record review, S4 completed the re-training on medications after the incident. Staff stated that S3 did not want to continue to pursue the MedTech position.

Based on review of S1 – S4’s staff training records, S1 – S4 completed multiple training courses regarding medications.

A deficiency was cited per California Code of Regulations, Title 22 regarding the medication errors. See LIC809-D. This report was reviewed with General Manager, Billy Mitchell and a copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2025 04:04 PM - It Cannot Be Edited


Created By: Christine Kabariti On 07/17/2025 at 03:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2025
Section Cited
CCR
87411(a)

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a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. … This requirement is not met as evidenced by:
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Licensee immediately removed the MedTechs who were part of the medication errors and the staff were required to re-complete medication training. Licensee will also provide in-service training to MedTech trainers regarding medication pass oversight.
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Based on interview and record review, the licensee did not ensure that staff were competent to assist residents with medication administration in 2 counts wherein 2 resident’s were administered another resident’s medication on 02/25/25 and 07/17/25 which poses 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 of 07/18/2025.

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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 Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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