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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 12/08/2022
Date Signed: 12/08/2022 01:56:29 PM

Document Has Been Signed on 12/08/2022 01:56 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:ATKINSON, DIANEFACILITY TYPE:
740
ADDRESS:7610 ISABELLA WAYTELEPHONE:
(206) 676-5300
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 214CENSUS: 155DATE:
12/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Diane AtkinsonTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived to the facility unannounced to open an initial complaint investigation. During visit, a case management visit was conducted. LPA met with Executive Director (ED) Diane Atkinson and Business Officer Director (BOD) Kippie Castronovo.

During the complaint investigation, LPA and ED toured the Garden House unit and it was observed staff (S1) was not associated to the facility personnel report summary. Upon the review of the Guardian Background Check System, it was determined S1’s application is incomplete therefore is not fingerprint cleared. S1 was immediately dismissed from work and was informed S1 would not be able to work at the facility until they obtain a fingerprint clearance. LPA provided S1 with the document that was mailed to S1's mailing address from Guardian. BOD confirmed S1 has been working in the facility for more than 5 days.

LPA observed three staff members who was not associated to the facility but are fingerprint cleared. Two out of three staff members were associated to the facility's old license. One out of three staff members (S2) is not associated to the facility and has been working in the facility for more than 5 days. BOD will submit the LIC9182 form along with other needed paperwork by end of business day.

Deficiencies were cited during today’s visit, see LIC 809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S1) working at the facility without fingerprint clearance. A second civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S2) working at the facility without association. Please see LIC 421BG.

Exit interview was conducted with Executive Director Diane Atkinson and a copy of the report was provided along with the appeal rights.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/08/2022 01:56 PM - It Cannot Be Edited


Created By: Christine Dolores On 12/08/2022 at 12:50 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: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2022
Section Cited
CCR
87355(e)(1)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or ... This requirement was not met as evidenced by:
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Staff (S1) was immediately dismissed from work and will not return until a fingerprint clearance has been obtained. Licensee agreed to submit a plan in writing to ensure all new staff are fingerprint cleared and associated to the facility.
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Based on record review, interview, and observation the Licensee did not comply with the section cited above for staff (S1) which poses an immediate health, safety, and personal rights risk to persons in care.
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Licensee will submit POC to LPA via email by POC due date.
Type A
12/09/2022
Section Cited
CCR87355(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or ... This requirement was not met as evidenced by:
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Licensee agreed to submit a plan in writing to ensure all new staff are fingerprint cleared and associated to the facility. Licensee will ensure to send necessary paperworks to the Department by end of day. Licensee will submit POC to LPA via email by POC due date.
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Based on record review, interview, and observation the Licensee did not comply with the section cited above for staff (S2) which poses an immediate health, safety, and personal rights risk to persons in care.
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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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
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