Inspection Reports for Merrill Gardens at Gilroy

The visit was an unannounced required 1-year annual inspection of the facility to assess compliance with licensing requirements.

The inspection found the facility generally compliant with no deficiencies cited. The elevator was out of order but functional manually with staff assistance. The kitchen, resident rooms, medication management, staff files, and safety equipment were all in good condition. Emergency drills and plans were up to date.

The inspection was conducted as an unannounced complaint investigation regarding an allegation that the licensee did not comply with a resident's admission agreement, resulting in the resident being charged excess fees.

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 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 visit was an unannounced case management legal/non-compliance inspection to ensure the facility is adhering to the compliance plan submitted after a non-compliance meeting held on June 13, 2024.

The inspection found that all required trainings per the non-compliance plan were completed, resident and staff files were complete and fingerprint cleared, and no deficiencies were cited. The facility was reminded to continue adherence to the corrective action plan and Title 22 regulations.

The visit was an unannounced case management - incident inspection to follow up on two incidents reported to the Department on 07/14/2025 and 07/17/2025 involving alleged abuse and a medication error.

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 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 visit was an unannounced case management visit to hand deliver an immediate exclusion letter for an individual who engaged in conduct inimical.

No deficiencies were cited during the visit. The immediate exclusion letter was delivered and the facility was instructed to remove the individual from contact with residents and the facility roster.

The inspection was conducted as an unannounced complaint investigation following a complaint received on 2025-06-03 alleging that facility staff did not give a resident medication as prescribed.

The investigation found that the allegation was unfounded. Staff interviews and record reviews confirmed that the resident continued to receive medication as prescribed, and no changes to the medication order were made. No deficiencies were cited.

The complaint alleged that staff did not give resident medication as prescribed. The allegation was investigated through interviews and record review and was found to be unfounded, meaning the allegation was false or without reasonable basis.

The visit was an unannounced case management – legal/non-compliance inspection to ensure the facility is adhering to the compliance plan submitted after a non-compliance meeting held on June 13, 2024.

The inspection found that all training topics stated in the non-compliance plan were completed, resident and staff files were in order, and no deficiencies were cited per California Code of Regulations, Title 22. The facility was reminded to continue adherence to the corrective action plan and Title 22 regulations.

This was an unannounced case management - incident follow-up visit conducted to investigate an allegation of neglect/lack of supervision resulting in a resident's suicide while in care.

The investigation found that the resident died by apparent suicide without assistance, with no evidence of suicidal ideation or depression noted in records. The allegation was determined to be unsubstantiated, and no deficiencies were cited under California Code of Regulations, Title 22.

The complaint involved an allegation of neglect/lack of supervision resulting in a resident's suicide. The allegation was investigated and found to be unsubstantiated due to lack of evidence of a Title 22 violation.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-05-24 regarding overcharging residents, falsifying documents, and failure to keep resident information confidential at Merrill Gardens at Gilroy.

The investigation found the allegations to be unsubstantiated based on interviews, record reviews, and observations. Residents and staff denied falsifying documents, and no evidence supported overcharging or confidentiality breaches. No deficiencies were cited.

The complaint included allegations that staff were overcharging residents for services not provided, falsifying documents by instructing staff not to document to avoid a paper trail, and disclosing a resident's death to other residents. Interviews with residents and staff, as well as record reviews, did not substantiate these allegations.

The visit was an unannounced case management – legal/non-compliance inspection to ensure the facility is adhering to the compliance plan submitted after a non-compliance meeting held on June 13, 2024.

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 visit was an unannounced complaint investigation triggered by a complaint received on 2024-03-28 alleging that staff did not follow a resident's care plan.

The investigation found the allegation to be unfounded based on staff interviews, record reviews, and observations. No deficiencies were cited, and it was determined that there was no requirement for hourly staff check-ins on the resident as alleged.

The complaint alleged that staff did not follow resident R1's care plan by failing to check on the resident every hour, resulting in an unwitnessed fall and injury. The allegation was found to be unfounded after investigation.

The inspection was an unannounced complaint investigation triggered by allegations received on 2024-05-23 regarding inadequate night supervision and delayed response to residents' call buttons at Merrill Gardens at Gilroy.

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 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 inspection was an unannounced complaint investigation triggered by allegations that facility staff took resident belongings and did not follow the resident's care plan.

The investigation substantiated the allegations that staff removed resident R1's medications from the resident's room without notifying the resident or authorized representatives, despite the care plan indicating no medication management was required. This posed an immediate health, safety, and personal rights risk. A deficiency was cited accordingly.

The complaint was received on 2024-02-26 and investigated with interviews, record reviews, and observations. The allegations were substantiated based on the preponderance of evidence standard.

The visit was conducted as a case management and complaint investigation following a reported incident of physical abuse by staff member S1 towards resident R1 on 12/02/2024.

The investigation found that staff member S1 engaged in conduct inimical to the facility by physically abusing resident R1, violating the resident's personal rights and causing bruises. An immediate exclusion letter was issued to S1 and a deficiency was cited under California Code of Regulations, Title 22.

The complaint investigation was substantiated. The incident involved physical abuse by staff S1 towards resident R1, resulting in immediate exclusion of S1 from the facility and termination of employment.

This was an unannounced follow-up case management incident visit initiated due to a resident's accidental death on 05/25/2024 and concerns about the facility's reassessment practices.

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 visit was an unannounced case management incident inspection to follow up on a physical abuse incident involving a staff member and a resident that occurred on 2024-12-02.

The investigation confirmed the incident was captured on video, the staff member involved was terminated, and the facility conducted internal investigations and staff training. No deficiencies were cited under California Code of Regulations, Title 22.

The complaint involved a physical abuse incident between staff member S1 and resident R1 on 2024-12-02. The incident was substantiated by video evidence. S1 was escorted out on 2024-12-03 and terminated on 2024-12-04. The facility conducted internal investigations and staff training following the incident.

The visit was an unannounced case management – legal/non-compliance inspection to ensure the facility is adhering to the compliance plan submitted after a non-compliance meeting held on June 13, 2024.

The Licensing Program Analyst observed that all required training topics from the non-compliance plan were completed by the expected dates, all sharp objects and chemicals were secured, and staff were fingerprint cleared. Five resident and five staff files were reviewed with no deficiencies cited under California Code of Regulations, Title 22.

The visit was an unannounced case management - deficiencies inspection based on violations observed during two complaint investigations (control numbers 26-AS-20221215152806 and 26-AS-20230714114133).

The facility failed to obtain updated physician's reports after changes in resident R1's condition, did not notify the physician of multiple falls sustained by R1, and did not follow up timely with the physician for an order of a nutritional beverage. Service plans were not signed or reviewed with R1 or the responsible party, posing potential health, safety, and personal rights risks.

The visit was triggered by two complaint investigations. One complaint involved failure to update physician reports and notify the physician of falls for resident R1. The second complaint involved failure to follow up with the physician for a nutritional beverage order for R1, which was delayed from March 2023 to June 2023.

An unannounced annual inspection visit was conducted to evaluate compliance with regulatory requirements at Merrill Gardens at Gilroy.

The facility was found to have functioning safety systems, adequate food supplies, and complete medication records. However, deficiencies were cited related to incomplete staff personnel records, specifically missing health screenings and TB results for two staff members.

An unannounced case management - other visit was conducted to review an amended complaint report and correct a civil penalty form related to a staff member working without a criminal background check clearance.

No deficiencies were cited per California Code of Regulations, Title 22. The correct civil penalty form was reviewed and signed by the Executive Director during the visit.

The visit included review of an amended complaint report for complaint control number 26-AS-20220404161647. A civil penalty was issued on 06/12/2024 for a staff member working without a criminal background check clearance.

The visit was an unannounced office non-compliance conference meeting conducted to address serious violations and deficiencies found during case management visits and complaint investigations, including failure to report a serious injury and resident's death within 24 hours.

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 visit was an unannounced case management - deficiencies inspection conducted due to a violation observed during a complaint investigation regarding staff criminal record clearance.

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

The visit was triggered by complaint control number 26-AS-20240524084602. The complaint was substantiated by finding that staff member S1 lacked a criminal record clearance.

The visit was an unannounced case management - incident inspection triggered by a resident's death reported on 2024-05-25 and the facility's failure to notify the Department within 24 hours.

The facility failed to report the death of resident R1 to the Department within the required 24-hour timeframe, posing an immediate health, safety, and personal rights risk. A deficiency was cited under California Code of Regulations, Title 22.

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 visit was an unannounced case management - incident inspection conducted to review a resident's records and investigate a reported incident.

No deficiencies were cited during the visit per California Code of Regulations, Title 22. The case management visit is pending further investigation.

The visit was triggered by a case management incident. The investigation is pending and no substantiation status is provided.

The visit was conducted to deliver an amended LIC809-D that was issued on 01/31/2023 and to review it with the Interim General Manager.

The Licensing Program Analyst arrived unannounced and met with the Interim General Manager to review and deliver the amended LIC809-D. The Interim General Manager signed the amended LIC809-D and was provided a copy.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff hit a resident in care.

The investigation found the allegation substantiated based on video evidence showing staff member S1 kneed resident R1 after a fall, posing an immediate health, safety, and personal rights risk. Staff S1 and S2 were terminated, and a deficiency was cited under California Code of Regulations, Title 22.

The complaint was substantiated based on video evidence and interviews. The allegation that staff hit a resident was confirmed, leading to termination of involved staff and citation of a deficiency.

The visit was conducted to deliver an immediate exclusion letter to exclude an employee (S1) at the facility.

Based on record review, the excluded employee (S1) is no longer employed at the facility. The immediate exclusion letter was handed to the Executive Director during the visit.

An unannounced case management visit was conducted to investigate deficiencies related to staff not being properly associated with the facility's personnel report summary and failure to submit transfer requests for staff.

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 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.

An unannounced initial complaint investigation and case management visit was conducted due to concerns about staff not being properly fingerprint cleared or associated with the facility.

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 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.

An unannounced complaint investigation visit was conducted in response to allegations received on 2021-10-12 regarding resident grooming needs, safeguarding of personal belongings, timely medical attention, and charging for services not rendered.

The investigation found that residents' grooming needs were being met, personal belongings were safeguarded according to facility policy, medical attention was sought in a timely manner, and the facility charged appropriately for services rendered. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint included allegations that residents' grooming needs were not met, staff did not safeguard personal belongings, staff did not seek medical attention timely, and the facility charged for services not rendered. After interviews with residents and staff, and review of records, all allegations were found unsubstantiated.

Unannounced pre-licensing continuation visit to evaluate the facility's readiness for licensing.

No issues were noted during the pre-licensing inspection. The facility was observed to be ready to be licensed, pending final approval by the Central Application Bureau.

The visit was an unannounced pre-licensing inspection conducted to evaluate the facility for licensing approval.

The facility was toured and observed to have appropriate furniture, lighting, safety equipment, and clean living areas. Medication storage, food storage temperatures, and safety devices were all found to be in compliance. The visit was not completed and a return visit was planned.

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report_33_435202806_inx32_2024-09-19.pdf

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report_31_435202806_inx30_2024-01-16.pdf

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report_30_435202806_inx29_2023-11-09.pdf

report_29_435202806_inx28_2023-01-31.pdf

report_4_435202806_inx3_2022-09-19.pdf

report_3_435202806_inx2_2021-09-07.pdf