<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 12/06/2024
Date Signed: 12/06/2024 12:18:52 PM

Document Has Been Signed on 12/06/2024 12:18 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:		KIM GOLDENFACILITY TYPE:
740
ADDRESS:7610 ISABELLA WAYTELEPHONE:
(206) 676-5300
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 214CENSUS: 146DATE:
12/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Jocelyne BailonTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a follow-up case management – incident visit that was initiated on 05/29/2024. LPA met with Health Services Director, Jocelyne Bailon.

On 05/25/2024, resident (R1) passed away at the facility and the cause of death was an accident. R1 had ligature strangulation in the setting of ethanol use. Based on R1’s evaluation report dated 11/30/2023, R1 had a history of substance use which may cause some interpersonal and/or health problems but does not significantly impair overall independent functioning. However, staff still had concerns about R1’s alcohol consumption and overall safety after drinking alcohol. Based on R1’s progress notes, R1 had multiple fall incidents from 2021 – 2024 resulting in injuries. Staff interviewed were aware that R1 was a fall risk, had multiple fall incidents and liked to drink alcohol.

The review of R1’s assessment shows R1 was last re-assessed on 11/30/2023, even though R1 continued to be a fall risk and had multiple falls resulting in injuries after 11/30/2023. There was no reassessment completed after 11/30/2024.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty of $1000 is being assessed today for a repeat violation within 12 months. See LIC421IM. Failure to correct the deficiency may result in additional civil penalties. An additional Civil Penalty for a violation resulting in serious bodily injury of a resident is pending review.

This report was reviewed with Health Services Director, Jocelyne Bailon and a copy of the report along with the appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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 12/06/2024 12:18 PM - It Cannot Be Edited


Created By: Christine Dolores On 12/06/2024 at 09:48 AM
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: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2024
Section Cited
CCR
87463(a)(3)

1
2
3
4
5
6
7
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) … This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee states they will reassess residents upon a change of condition immediately. Licensee will submit a statement of understanding of the section cited and the plan going forward, to LPA Dolores via email by POC due date (12/07/24).
8
9
10
11
12
13
14
Based on interview, record review, and observation the licensee did not comply with the section cited above wherein the facility did not reassess R1 after 11/30/2023, even though R1 continued to be a fall risk and had multiple falls resulting in injuries after 11/30/2023 which poses an immediate health, safety and personal rights risk to persons in care.
8
9
10
11
12
13
14

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
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2