435202806-11-9-2023-26-AS-KHOS-CZ4JS2-20240102061735

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202806
Report Date: 11/09/2023
Date Signed: 11/09/2023 11:16:49 AM

Unfounded

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
11/02/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20231102093634

FACILITY NAME:	MERRILL GARDENS AT GILROY		FACILITY NUMBER:	435202806
ADMINISTRATOR:	NELSON RODRIGUES		FACILITY TYPE:	740
ADDRESS:	7610 ISABELLA WAY		TELEPHONE:	(206) 676-5300
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	214	CENSUS: 142	DATE:	11/09/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Jocelyn Bailon		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not seek medical attention for resident in a timely manner.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Garden House Director (GHD) Jocelyn Bailon.

On 11/02/2023, the Department received a complaint alleging facility staff did not seek medical attention for resident (R1)’s in a timely manner. It was alleged, R1 can hardly walk somedays because R1’s bunions are red and they hurt. On 11/09/2023, the initial complaint investigation was conducted.

The following documents were obtained for this investigation to include R1’s physician’s report, needs and services plan, preplacement appraisal information, identification and emergency information, progress notes, and POA documents.

SEE LIC9099-C.

Unfounded

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: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 26-AS-20231102093634

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: 11/09/2023

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
26
27
28
29
30
31
32

On 11/09/2023, 4 staff members were interviewed. Based on interview, the facility staff was unaware of any concerns regarding R1’s feet and bunions. 4 out of 4 staff states R1 has never complained of any pain. 4 out of 4 staff denied any observation of redness on R1’s feet. 4 out of 4 staff state R1 is constantly walking around Garden House and has never complained of any pain. S4 states to observe R1 was limping one day and when asked if R1 was in pain, R1 denied any feeling of pain and continued to walk around Garden House. 4 out of 4 staff state R1’s family and/or visitor has not addressed any concerns regarding R1’s bunions and feet.

On 11/09/2023, 1 witness was interviewed. Based on interview, R1 has been complaining that his/her feet were hurting for “quite a while”, however, the facility was not informed of that information when R1 moved in.

Based on records reviewed, there was no indication of medical concerns relating to R1’s bunions and/or feet. There was also no indication R1 complained of any pain which may prompt facility staff to seek medical attention.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded meaning the allegation is false could not have happened and/or is without a reasonable basis. This report was reviewed with Garden House Director, Jocelyn Bailon and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2