Inspection Reports for
Merrill Gardens at Gilroy

The complaint was received on 2025-07-10 alleging noncompliance with the resident’s admission agreement resulting in excess fees charged. The allegation was substantiated based on interviews, record review, and observation.

The investigation substantiated the allegation that the licensee failed to credit the resident for assisted living care services during a hospitalization period as required by the admission agreement. The credit was eventually processed after the investigation, and a deficiency was cited under California Code of Regulations, Title 22.

The visit was complaint-related following reports of alleged abuse between a resident and private caregiver on 07/14/2025 and a medication error on 07/17/2025. The abuse allegation was unsubstantiated with no visible injuries or indications of abuse. The medication error was substantiated with two incidents of wrong medication administration by MedTechs in training.

The investigation found no visible injuries or indications of abuse related to the alleged abuse incident. However, a medication error was confirmed where a MedTech in training administered the wrong resident's medication on two occasions, posing an immediate health and safety risk. The facility removed involved staff and required re-training.

The visit was complaint-related, following up on alleged abuse between a resident and private caregiver reported on 07/14/2025 and a medication error reported on 07/17/2025. The abuse allegation was not substantiated due to lack of visible injuries and no indications of abuse. The medication error was substantiated with corrective actions required.

The investigation found no visible injuries or indications of abuse related to the alleged abuse incident on 07/14/2025. A medication error was confirmed on 07/17/2025 where a MedTech in training administered the wrong resident's medication. A similar medication error had occurred previously on 02/25/2025. A Type A deficiency was cited for staff competency related to medication administration.

The inspection found that the facility had completed required staff training as per the non-compliance plan and maintained documentation of resident and staff files. However, a deficiency was cited for failing to keep toxic items inaccessible to a resident diagnosed with dementia, posing an immediate health, safety, and personal rights risk.

The complaint investigation was substantiated based on interviews, record reviews, and observations. Allegations included inadequate night supervision and delayed response to call buttons. The allegation that a resident was left without bed sheets was unsubstantiated.

The investigation substantiated that the facility did not have adequate night supervision on Sundays and Mondays in May 2024, with only one caregiver scheduled instead of the standard two, and staff did not respond to residents' call buttons within the expected 15-minute timeframe, with many calls delayed over 30 minutes. Another allegation that a resident was left without bed sheets overnight was unsubstantiated.

The complaint investigation was substantiated. The incident involved physical abuse by staff S1 towards resident R1 on 12/02/2024. S1 was escorted out on 12/03/2024 and terminated on 12/04/2024. The department issued an immediate exclusion letter to S1.

The investigation found that staff member S1 engaged in aggressive actions towards resident R1, violating the resident's personal rights and causing physical injury. The staff member was immediately excluded and terminated, and a deficiency was cited under California Code of Regulations for personal rights violations.

The facility failed to reassess a resident (R1) after 11/30/2023 despite multiple falls and continued fall risk, resulting in a cited deficiency and a $1000 civil penalty for a repeat violation. An additional civil penalty for serious bodily injury is pending review.

The complaint investigation was substantiated regarding the facility's failure to respond to the resident's call button on seven occasions, based on record review and observation. The allegation that staff did not honor the resident's wishes to go to the hospital was unsubstantiated. Allegations about POA document acceptance and resident voice in memory care were unfounded.

The investigation substantiated that the facility failed to respond to a resident's call button on seven occasions, posing an immediate health and safety risk, resulting in a cited deficiency. The allegation that staff did not honor the resident's hospital wishes was unsubstantiated. Allegations regarding refusal to accept POA documents and lack of resident voice in memory care were unfounded with no deficiencies cited.

The visit was complaint-related based on two complaint control numbers 26-AS-20221215152806 and 26-AS-20230714114133. The complaints involved failure to update physician reports, failure to notify physicians of falls, and failure to follow up on physician orders for nutritional beverages.

The facility failed to obtain updated physician's reports after changes in resident R1's condition, did not ensure service plans were signed by R1 and the responsible party, and failed to notify the physician of multiple falls sustained by R1. Additionally, the facility did not follow up with the physician for an order of a nutritional beverage until several months after the physician's report.

The facility was generally well maintained with proper food storage, functioning resident rooms, and safety equipment in place. However, deficiencies were cited related to incomplete staff personnel records, specifically missing health screenings and TB results for two staff members.

The complaint investigation was substantiated. Allegations included rough handling of resident R1 by staff member S1 on 06/13/2022 and failure to inform R1's family of changes in condition. Evidence included staff interviews, police statements, medical records, and observation of bruising. Staff member S1 was reassigned to assisted living and no longer works in memory care.

The investigation substantiated that a staff member (S1) roughly handled resident (R1) on 06/13/2022 causing bruising and injury, and that the facility failed to promptly notify the resident's family of R1's shoulder pain and condition changes. Staff interviews, police reports, and record reviews supported these findings.

Deficiencies were found during case management visits and complaint investigations, including failure to report a serious injury and resident's death within 24 hours to Licensing. Repeat violations included failure to associate staff members to the facility's roster and failure to obtain criminal record clearances prior to staff starting work.

The report identified multiple serious violations related to reporting requirements, observation of residents, personal rights, reappraisals, criminal record clearances, and care of persons with dementia. The Administrator failed to demonstrate knowledge of applicable laws and regulations, resulting in serious violations posing immediate health and safety risks. An additional civil penalty for a violation resulting in serious injury is pending review.

The report details multiple serious violations related to reporting requirements, observation of residents, personal rights, reappraisals, criminal record clearance, and care of persons with dementia. The Administrator failed to exhibit knowledge of applicable laws and regulations, resulting in serious violations posing immediate health, safety, and personal rights risks. An additional civil penalty for violation resulting in serious injury is pending review.

The complaint investigation for control number 26-AS-20240524084602 found that staff member S1 did not have a criminal record clearance prior to working at the facility. The violation was substantiated and resulted in a deficiency citation and civil penalty.

A deficiency was cited for a staff member working without obtaining a criminal record clearance, posing an immediate health, safety, and personal rights risk. A civil penalty of $500 was assessed for this violation.

The visit was complaint-related due to the facility's failure to notify the Department of a resident's death within 24 hours. The case management visit is pending investigation.

The facility did not notify the Department of the resident's death within the required 24-hour timeframe, resulting in a cited deficiency under California Code of Regulations, Title 22, Section 87211(a)(2). The case management visit is pending further investigation.

The complaint was substantiated. The complaint control number is 26-AS-20230828135509. The complaint alleged severe neglect of a resident resulting in injuries after a fall and being found covered with ants. The investigation found that staff failed to monitor the resident as required, the resident was found injured on the floor with ants on their body, and the facility had ongoing ant issues.

The investigation substantiated the allegations that the facility failed to properly monitor and care for the resident after hospital discharge, resulting in the resident being found injured on the floor with ants on their body. The facility also had ongoing issues with ants. Deficiencies were cited and an immediate civil penalty of $500 was assessed.

The complaint was substantiated based on video evidence and interviews. The Department found that staff hit a resident in care, meeting the preponderance of evidence standard. Staff involved were terminated and a deficiency was cited.

The investigation substantiated the allegation that staff member S1 kneed resident R1 on the left side after failing to assist the resident back onto a wheelchair following a fall, posing an immediate health, safety, and personal rights risk. Staff members S1 and S2 were terminated, and a deficiency was cited under California Code of Regulations, Title 22.

The visit was complaint-related, investigating staff not associated with the facility’s personnel report summary and failure to send transfer requests. The complaint was substantiated as deficiencies were cited and penalties assessed.

The facility was found to have staff members (S1 and S2) working without a required transfer request, which posed an immediate health, safety, and personal rights risk to persons in care. Deficiencies were cited and civil penalties assessed for repeat violations.

The complaint investigation was initiated due to staff working without proper fingerprint clearance and association. The findings substantiated that staff (S1) and (S2) were non-compliant, posing immediate risks to persons in care.

The investigation found that one staff member (S1) was working without fingerprint clearance and another staff member (S2) was working without proper association to the facility. Both posed immediate health, safety, and personal rights risks. Civil penalties were assessed for these violations.

The facility was generally compliant with infection control measures, including PPE use and environmental cleanliness; however, a deficiency was cited for having multiple sharp gardening tools and toxins accessible in the community garden, posing an immediate health and safety risk to residents with dementia.