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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202806
Report Date: 01/31/2023
Date Signed: 01/31/2023 03:13:32 PM


Document Has Been Signed on 01/31/2023 03:13 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: 151DATE:
01/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Nelson RodriguesTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – deficiencies visit. LPA met with Executive Director, Nelson Rodrigues.

During a complaint investigation, LPA observed staff (S1) and staff (S2) were not associated to the facility’s personnel report summary. Based on record review and interview, the facility did not send the Department a request for transfer.

S1 and S2 are not current employees of the facility and were terminated as of the middle of January 2023.

A deficiency was cited during today’s visit, see LIC809-D. A civil penalty for repeat violation within the 12-month period is being assessed for the amount of $3,000 ($100 per day x 30 days = $3,000), for staff (S1) working at the facility without a transfer request. A second civil penalty for repeat violation within the 12-month period is being assessed for the amount of $3,000 ($100 per day x 30 days = $3,000), for staff (S2) working at the facility without a transfer request. See LIC421BG.

A plan of correction was developed with Executive Director, Nelson Rodrigues. Exit interview conducted and a copy of the report and appeals rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (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.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/15/2023 04:29 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/11/2023 01:08 PM

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

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
87355(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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Staff (S1) and (S2) are no longer employees at the facility. Licensee will ensure all new and current staff are fingerprint cleared and associated to the facility. Licensee will submit a plan in writing to ensure all new staff are associated to the facility prior to starting work.
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Based on record review, interview, and observation the Licensee did not comply with the section cited above by not requesting a transfer to associate S1 and S2 to the facility prior to individuals starting work, which poses an immediate health, safety, and personal rights risk to persons in care.
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 Licensee will also submit a plan in writing to audit their facility roster to ensure all current staff are fingerprint cleared and associated to the facility. Licensee will review section 87355 and send a statement of understand of the section and send the facility’s plan 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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (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
LIC809 (FAS) - (06/04)
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