435202806-1-31-2023-26-AS-KHOS-CP2TED-20230214133945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202806
Report Date: 01/31/2023
Date Signed: 01/31/2023 03:10:36 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2023 and conducted by Evaluator Christine Dolores

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230118132028

FACILITY NAME:	MERRILL GARDENS AT GILROY		FACILITY NUMBER:	435202806
ADMINISTRATOR:	ATKINSON, DIANE		FACILITY TYPE:	740
ADDRESS:	7610 ISABELLA WAY		TELEPHONE:	(206) 676-5300
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	214	CENSUS:	DATE:	01/31/2023
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Nelson Rodrigues		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff hit resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding for the above allegation. LPA met with Executive Director, Nelson Rodrigues.

On 01/18/2023, the Department received the complaint. The initial complaint investigation was conducted on 01/25/2023.

Documents obtained for the investigation included the resident roster, staff roster, S1 – S2’s application and signed mandated reporter form, R1’s physician’s report, needs and services plan, and progress notes from 12/28/2022 – 01/25/2023. A clip of the video from the incident was also obtained.

See LIC9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230118132028

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/31/2023

NARRATIVE

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On 12/28/2022, a video from the facility’s fall detection program recorded a video of R1’s fall. During the video, S1 and S2 are seen attempting to assist R1 back onto the wheelchair. After failing to assist R1, the video shows S1 quickly knee R1 on the left side causing R1 to budge.

Based on interview and record review, S1 – S2 has been terminated from the facility.

The Department has investigated the above allegation and the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D.

A plan of correction was developed with the Executive Director, Nelson Rodrigues and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230118132028

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/31/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/01/2023 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	(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:	1 2 3 4 5 6 7	The Licensee has completed staff training on personal rights after the incident. Licensee has conducted a town hall meeting and all-staff meeting regarding resident rights and the responsibilities of a mandated reporter.
	8 9 10 11 12 13 14	Based on interview and observation of the fall detection video, it was evident that after S1 and S2 failed to assist R1 back onto the wheelchair after a fall, S1 kneed R1 on the left side causing R1 to budge, which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14	Licensee will also provide an in-service training to all staff on the proper ways to assist a resident after a fall. Licensee will submit the training documents and meeting agenda to LPA by POC due date via email.
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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	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC9099 (FAS) - (06/04)

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