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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 12/10/2024
Date Signed: 12/10/2024 11:22:27 AM

Document Has Been Signed on 12/10/2024 11:22 AM - 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: 140DATE:
12/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Billy MitchellTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Dolores and Marcella Tarin arrived unannounced to conduct a case management visit to deliver an immediate exclusion letter for staff (S1). LPAs met with General Manager (GM), Billy Mitchell.

On 12/06/2024, the Department conducted an initial visit to investigate a reported incident involving physical abuse to resident (R1) by staff (S1). The incident occurred on the night of 12/02/2024 and the facility was informed on 12/03/2024. On 12/03/2024, S1 was escorted out of the building and on 12/04/2024, S1's employment was terminated from the facility.

LPAs provided a letter "Order to Licensee/Facility of Immediate Exclusion From Facility" That the department determine that S1 engaged in conduct inimical as a staff in the facility. GM was informed to remove S1 from any contact with residents and S1 may not be physically present in any facility.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. The Department issued a citation under 87468.1(a)(3) Personal Rights. S1's aggressive action towards R1 violated R1's personal rights when S1 quickly dragged R1 across the room to the bathroom, covered R1's mouth, and pushed R1 to the ground causing R1 to sustain bruises on his/her shoulder area and toes.

This report was reviewed with General Manager (GM) Billy Mitchell 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: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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Document Has Been Signed on 12/10/2024 11:22 AM - It Cannot Be Edited


Created By: Christine Dolores On 12/10/2024 at 09:10 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: 12/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2024
Section Cited
CCR
87468.1(a)(3)

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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature,... This requirement is not met as evidenced by:
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Licensee terminated S1 on 12/4/2024. Licensee conducted an in-service training after the incident on 12/4/24 and 12/5/24 to include topics of understanding the importance of “see something say something”;
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Based on interview, record review and observation S1's aggressive actions towards R1, the night of 12/02/2024 violated R1's personal rights, which poses/posed an immediate health, safety, and personal rights risk to persons in care.
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mandated reporters; the steps to take to ensure residents safety and well-being; and understanding resident rights. Deficiency was cleared during visit.

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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: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
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