Inspection Reports for Merrill Gardens at Gilroy
7600 Isabella Way, Gilroy, CA 95020, CA, 95020
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. However, there were multiple substantiated deficiencies over time, primarily involving resident care issues such as failure to update care plans after falls, inadequate staff response to call buttons, medication administration errors, and incidents of physical abuse by staff. The facility also faced enforcement actions including civil penalties totaling at least $1,500 and staff exclusions due to abuse and working without proper clearances. The most recent report from September 25, 2025, was clean with no deficiencies cited, showing improvement from earlier findings. While some serious issues occurred in prior years, recent inspections suggest the facility has addressed many concerns and is currently operating in compliance with licensing requirements.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
64% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 136
Capacity: 214
Deficiencies: 0
Date: Sep 25, 2025
Visit Reason
The visit was an unannounced required 1-year annual inspection of the facility to assess compliance with licensing requirements.
Findings
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.
Report Facts
Hot water temperature: 115.5
Fire extinguisher last serviced: 2025
Number of resident bedrooms observed: 9
Number of resident records reviewed: 7
Number of residents on medication management: 5
Number of staff files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met during inspection and discussed elevator issue |
| Jocelyn Bailon Saloche | Health Services Director | Accompanied Licensing Program Analyst during facility tour |
| Christine Kabariti | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 214
Deficiencies: 1
Date: Sep 25, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
The licensee did not comply with the terms and conditions set forth in resident (R1)’s admission agreement by not ensuring R1 was credited assisted living care services costs per the admission agreement timeframe, posing a potential health, safety, and personal rights risk.
Report Facts
Capacity: 214
Census: 136
Deficiency count: 1
Plan of Correction Due Date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with Licensing Program Analyst during investigation and involved in crediting resident's account |
| Christine Kabariti | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jackie Jin | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Monitoring
Capacity: 214
Deficiencies: 0
Date: Aug 19, 2025
Visit Reason
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.
Findings
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.
Report Facts
Staff on schedule: 14
Resident files reviewed: 5
Staff files reviewed: 5
Capacity: 214
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with Licensing Program Analyst during inspection and discussed compliance plan adherence |
| Jocelyne Bailon Saloche | Health Services Director | Met with Licensing Program Analyst during inspection |
| Christine Kabariti | Licensing Program Analyst | Conducted the unannounced case management legal/non-compliance visit |
Inspection Report
Complaint Investigation
Capacity: 214
Deficiencies: 1
Date: Jul 17, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility personnel were not competent to assist residents with medication administration, resulting in two incidents where residents were administered another resident's medication on 02/25/2025 and 07/17/2025.
Report Facts
Facility capacity: 214
Medication error incidents: 2
Plan of Correction due date: Jul 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met during inspection and involved in review of findings |
| Christine Kabariti | Licensing Program Analyst | Conducted the inspection and authored the report |
| Jackie Jin | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 134
Capacity: 214
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
The visit was an unannounced case management visit to hand deliver an immediate exclusion letter for an individual who engaged in conduct inimical.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with Licensing Program Analyst during the visit and was informed about the immediate exclusion letter. |
| Christine Kabariti | Licensing Program Analyst | Conducted the unannounced case management visit and delivered the immediate exclusion letter. |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 214
Deficiencies: 0
Date: Jun 6, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 214
Census: 144
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Kabariti | Licensing Program Analyst | Conducted the complaint investigation |
| Jocelyne Bailon Saloche | Health Services Director | Met with Licensing Program Analyst during investigation and reviewed report |
Inspection Report
Monitoring
Census: 138
Capacity: 214
Deficiencies: 0
Date: May 28, 2025
Visit Reason
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.
Findings
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.
Report Facts
Staff on schedule during PM shift: 9
Resident files reviewed: 5
Staff files reviewed: 5
Compliance plan duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met during inspection and advised regarding compliance plan adherence |
| Jocelyne Bailon Saloche | Health Services Director | Met during inspection and accompanied LPA during room checks |
| Christine Kabariti | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Follow-Up
Census: 140
Capacity: 214
Deficiencies: 0
Date: Apr 9, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 214
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with during the inspection and involved in the investigation |
| Christine Kabariti | Licensing Program Analyst | Conducted the case management - incident visit |
| Jackie Jin | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 214
Deficiencies: 0
Date: Apr 9, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 214
Census: 140
Number of allegations: 3
Number of residents interviewed: 6
Number of staff interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with Licensing Program Analyst during investigation and reviewed report |
| Christine Kabariti | Licensing Program Analyst | Conducted the complaint investigation |
| Nelson Rodrigues | Administrator | Facility administrator named in report header |
| Jackie Jin | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| S1 | Staff Member | Alleged to have instructed falsification of documents and disclosure of resident death; denied allegations |
| S2 | Staff Member | Interviewed regarding falsification allegations; denied involvement |
| S3 | Staff Member | Reported former staff was told not to document everything |
| S4 | Staff Member | Interviewed regarding confidentiality allegation |
Inspection Report
Monitoring
Census: 141
Capacity: 214
Deficiencies: 1
Date: Feb 20, 2025
Visit Reason
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.
Findings
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.
Deficiencies (1)
Failure to ensure disinfectants, cleaning solutions, poisonous substances, and other similar items were kept in locked storage and not accessible to a resident diagnosed with dementia, posing an immediate health, safety, and personal rights risk.
Report Facts
Capacity: 214
Census: 141
Staff fingerprint cleared: 11
Training completion date: Jul 18, 2024
Plan of Correction Due Date: Feb 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with Licensing Program Analyst during inspection and discussed compliance plan |
| Jocelyne Bailon | Health Services Director | Informed resident and removed accessible chemicals during inspection |
| Christine Kabariti | Licensing Program Analyst | Conducted the inspection and authored the report |
| Jackie Jin | Licensing Program Manager | Supervisor of the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 214
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with during the investigation and report review |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Yip | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 214
Deficiencies: 1
Date: Dec 19, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Licensee did not ensure enough staff scheduled in prom and plaza during the night shift in May 2024 and did not ensure staff responded to residents' call buttons within 15 minutes, posing immediate health, safety, and personal rights risks.
Report Facts
Capacity: 214
Census: 139
Pendant calls with response time >=10 minutes: 88
Pendant calls with response time >30 minutes: 33
Pendant calls with response time >15 minutes: 26
Pendant calls with response time >=10 minutes: 55
Pendant calls with response time >30 minutes: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with Licensing Program Analyst during investigation and report review |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sarah Yip | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 214
Deficiencies: 1
Date: Dec 19, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to inform resident and authorized representatives prior to removing resident's medications from the room, violating personal rights under CCR 87468.1(a)(8).
Report Facts
Capacity: 214
Census: 139
Plan of Correction Due Date: Dec 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with Licensing Program Analyst during investigation and named in findings |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Yip | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 214
Deficiencies: 1
Date: Dec 10, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
S1's aggressive actions towards R1 on 12/02/2024 violated R1's personal rights by dragging R1 across the room, covering R1's mouth, and pushing R1 to the ground causing bruises.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with Licensing Program Analysts during the visit and was informed of the exclusion letter and findings |
| Christine Dolores | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Marcella Tarin | Licensing Program Analyst | Conducted the case management visit |
| Sarah Yip | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 214
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2023-07-24 alleging multiple issues including failure to safeguard resident's personal belongings, unmet hygiene needs, unclean linens, and unsafe sanitation practices.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included failure to safeguard dentures, unmet hygiene needs due to short staffing, unclean linens, and unsafe sanitation practices. Interviews with 4 staff members and record reviews did not support the allegations. Infection control training was verified. No deficiencies were cited.
Findings
The investigation found that the resident (R1) refused to wear dentures and staff did not recall R1 using dentures. Hygiene needs, shower schedules, and linen changes were maintained according to staff interviews and records. Allegations of unsafe sanitation practices were denied by staff and infection control training was confirmed. The allegations were determined to be unsubstantiated with no deficiencies cited.
Report Facts
Capacity: 214
Census: 146
Staff interviewed: 4
Infection control training date: May 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jocelyne Bailon | Health Services Director | Met with Licensing Program Analyst during investigation |
| Nelson Rodrigues | Administrator | Facility administrator named in report header |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 156
Capacity: 214
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility did not seek medical care for residents exhibiting symptoms of scabies, failed to communicate with residents' physicians about changes in condition, did not quarantine symptomatic residents, and did not discard PPE gowns after assisting residents with contagious disease.
Complaint Details
The complaint alleged failure to seek medical care and communicate with physicians for residents with scabies symptoms, failure to quarantine symptomatic residents, and failure to discard PPE gowns after use. The investigation included interviews with 6 staff members and review of resident records. The allegations were determined to be false and without reasonable basis.
Findings
Based on staff interviews, record reviews, and observations, the allegations were found to be unfounded. Residents with confirmed scabies were treated and isolated appropriately, PPE gowns were discarded after use, and no deficiencies were cited under California Code of Regulations, Title 22.
Report Facts
Number of residents with alleged symptoms: 5
Number of staff interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jocelyne Bailon | Health Services Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Follow-Up
Census: 146
Capacity: 214
Deficiencies: 1
Date: Dec 6, 2024
Visit Reason
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.
Findings
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.
Deficiencies (1)
The facility did not update the pre-admission appraisal or reassess the resident after 11/30/2023 despite continued fall risk and multiple falls resulting in injuries.
Report Facts
Civil penalty amount: 1000
Capacity: 214
Census: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jocelyne Bailon | Health Services Director | Met with Licensing Program Analyst during inspection and discussed findings |
| Christine Dolores | Licensing Program Analyst | Conducted the follow-up case management incident visit |
| Sarah Yip | Licensing Program Manager | Supervisor and reviewer of the report |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 214
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 214
Census: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jocelyne Bailon | Health Services Director | Met with Licensing Program Analyst during the inspection and involved in the incident follow-up |
| Christine Dolores | Licensing Program Analyst | Conducted the unannounced case management incident visit |
| Kim Golden | Administrator/Director | Named as facility administrator/director |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 214
Deficiencies: 0
Date: Oct 29, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility does not have sufficient staffing in memory care to meet the needs of residents.
Complaint Details
The complaint alleged insufficient staffing in memory care, with only an average of 2 caregivers daily and caregivers performing housekeeping chores that limited care time. The investigation included interviews with staff and a witness, observation of staffing during the visit, and review of staffing schedules from July and August 2023. The allegation was determined unsubstantiated as evidence did not support the claim.
Findings
Based on interviews, record review, and observations, the allegation of insufficient staffing in memory care was found to be unsubstantiated. Staffing schedules and staff interviews indicated adequate staffing levels, and no deficiencies were cited.
Report Facts
Capacity: 214
Census: 142
Memory care residents: 30
Staffing levels: 3
Staffing levels: 1
Staffing levels: 2
Staffing levels: 2
Staff interviewed: 8
Staff agreeing sufficient: 7
Staff disagreeing sufficient: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Billy Mitchell | General Manager | Met with Licensing Program Analyst during investigation and reviewed report |
| Nelson Rodrigues | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Capacity: 214
Deficiencies: 1
Date: Oct 29, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple complaints received on 10/10/2023 regarding the facility's call button operability and reachability, honoring resident wishes to go to the hospital, acceptance of resident's POA documents, and resident voice in memory care.
Complaint Details
The complaint investigation was substantiated regarding the call button issue, unsubstantiated regarding failure to honor resident's hospital wishes, and unfounded regarding POA document acceptance and resident voice in memory care.
Findings
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 wishes to go to the hospital was unsubstantiated. Allegations regarding the facility not accepting POA documents and not allowing the resident a voice in memory care were found unfounded with no deficiencies cited.
Deficiencies (1)
Failure to respond to resident's call button on seven occasions, posing immediate health, safety, and personal rights risk.
Report Facts
Capacity: 214
Unanswered call button alerts: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Billy Mitchell | General Manager | Met with Licensing Program Analyst during investigation and report review |
| Sarah Yip | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Census: 214
Capacity: 214
Deficiencies: 0
Date: Oct 29, 2024
Visit Reason
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.
Findings
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.
Report Facts
Staff observed: 9
Resident files reviewed: 5
Staff files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with Licensing Program Analyst during inspection and discussed compliance plan adherence |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kim Golden | Administrator/Director | Named as facility administrator/director |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 214
Deficiencies: 0
Date: Oct 7, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff pureed a resident's food without authorization and did not accommodate the resident's diet needs by failing to provide a nutritional beverage.
Complaint Details
The complaint alleged that staff pureed resident R1's food without authorization and failed to accommodate R1's diet needs by not providing a nutritional beverage. The investigation revealed that the resident's responsible party had provided a diet order for pureed food dated 04/21/2023, and although a physician's report in March 2023 indicated a special diet for a nutritional beverage, the facility did not have an actual physician's order until June 2023. The allegations were unsubstantiated due to insufficient evidence to prove violations.
Findings
The investigation found the allegations to be unsubstantiated based on staff interviews and record reviews, including physician orders and dietary communications. No deficiencies were cited, but a case management visit was conducted due to a violation observed during the investigation.
Report Facts
Facility capacity: 214
Census: 141
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with Licensing Program Analyst during investigation and report review |
| Jocelyn Bailon Solache | Resident Care Director | Met with Licensing Program Analyst during investigation |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Yip | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 214
Deficiencies: 3
Date: Oct 7, 2024
Visit Reason
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).
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to obtain an updated physician’s report for resident R1 after changes in condition and re-evaluations.
Failure to arrange meetings with resident R1, responsible party, and appropriate staff after significant changes in condition.
Failure to immediately notify resident R1’s physician and responsible party of changes, including multiple falls.
Report Facts
Falls sustained by resident R1: 7
Plan of Correction (POC) due date: Oct 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with Licensing Program Analyst during inspection and reviewed report. |
| Jocelyne Bailon Solache | Resident Care Director | Met with Licensing Program Analyst during inspection. |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Sarah Yip | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 214
Deficiencies: 1
Date: Oct 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that facility staff were not reappraising a resident after falls, resulting in injuries due to multiple falls.
Complaint Details
The complaint investigation was substantiated for failure to reappraise resident after falls causing injuries. The allegation of lack of supervision resulting in multiple falls was unsubstantiated.
Findings
The investigation substantiated that the facility failed to re-evaluate and update the resident's service plan after multiple falls, resulting in injuries. A deficiency was cited for not updating the pre-admission appraisal as required. Another allegation regarding lack of supervision resulting in multiple falls was unsubstantiated.
Deficiencies (1)
The licensee did not ensure resident (R1) was re-evaluated and service plans updated after falls resulting in injuries, violating CCR 87463(a).
Report Facts
Falls recorded: 22
Deficiency citations: 1
Capacity: 214
Census: 141
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Billy Mitchell | General Manager | Met with Licensing Program Analyst during investigation and report review. |
| Jocelyne Bailon Solache | Resident Care Director | Met with Licensing Program Analyst during investigation. |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 214
Deficiencies: 0
Date: Oct 7, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that facility staff did not treat residents politely and verbally and physically abused residents.
Complaint Details
The complaint was received on 04/04/2023 alleging staff impoliteness, verbal abuse, and physical abuse of residents. After investigation including interviews and record review, the allegations were determined to be false and without reasonable basis.
Findings
Based on interviews with 7 residents and 5 staff members, as well as record review and observation, the allegations were found to be unfounded. No deficiencies were cited under California Code of Regulations, Title 22.
Report Facts
Residents interviewed: 7
Staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with Licensing Program Analyst during investigation and report review |
| Jocelyne Bailon Solache | Resident Care Director | Met with Licensing Program Analyst during investigation |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Yip | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Capacity: 214
Deficiencies: 1
Date: Sep 19, 2024
Visit Reason
An unannounced annual inspection visit was conducted to evaluate compliance with regulatory requirements at Merrill Gardens at Gilroy.
Findings
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.
Deficiencies (1)
Staff (S1) and (S4) health screening and TB result was not on file, posing a potential health, safety and personal rights risk to persons in care.
Report Facts
Capacity: 214
Staff records reviewed: 6
Resident records reviewed: 5
Resident bedrooms toured: 7
Plan of Correction due date: Sep 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with during inspection and involved in findings discussion |
| Jocelyn Bailon | Health Services Director | Met with during inspection |
| Marcella Tarin | Licensing Program Analyst | Conducted inspection and authored report |
| Kim Golden | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 214
Deficiencies: 2
Date: Sep 19, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/24/2022 regarding rough handling of a resident by staff and failure to inform the resident's family of a change in condition.
Complaint Details
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.
Findings
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 (2)
Residents must be free from punishment, humiliation, intimidation, abuse, or other punitive actions; the licensee did not ensure resident (R1) was free from abuse by staff (S1) who handled R1 roughly on 06/13/2022.
The licensee shall immediately bring any changes to the attention of the resident's physician and family or responsible person; the licensee did not ensure immediate notification to R1's family of shoulder pain and condition changes.
Report Facts
Capacity: 214
Census: 140
Deficiencies cited: 2
Plan of Correction Due Date: Sep 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with Licensing Program Analysts during investigation and reviewed report |
| Jocelyn Bailon | Health Services Director | Reviewed report and appeal rights with Licensing Program Analysts |
| Christine Dolores | Licensing Program Analyst | Conducted complaint investigation and signed report |
| Sarah Yip | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 214
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that the facility's Garden House memory care section does not have enough staff to meet the needs of residents in care.
Complaint Details
The complaint alleged insufficient staffing in the Garden House memory care section. The investigation included interviews with staff, observation of staffing levels, and review of schedules and resident records. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
Based on interviews, record review, and observation, the allegation was found to be unsubstantiated. The facility demonstrated adequate staffing levels with ongoing hiring efforts, and no deficiencies were cited.
Report Facts
Facility capacity: 214
Resident census: 140
Memory care residents: 35
Caregivers per shift: 4
Medtechs per shift: 1
Night shift caregivers: 2
Agency staff frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | General Manager | Met with Licensing Program Analysts during the investigation |
| Jocelyn Bailon | Health Services Director | Report reviewed with this employee |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Marcella Tarin | Licensing Program Analyst | Arrived unannounced to deliver findings |
| Sarah Yip | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Capacity: 214
Deficiencies: 0
Date: Jun 24, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Facility capacity: 214
Civil penalty date: Jun 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Golden | Executive Director | Met with Licensing Program Analyst during visit and signed civil penalty form |
| Christine Dolores | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Enforcement
Capacity: 214
Deficiencies: 5
Date: Jun 13, 2024
Visit Reason
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.
Findings
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.
Deficiencies (5)
Failure to report a serious injury and resident's death within 24 hours to Licensing.
Failure to associate 4 staff members to the facility's roster prior to staff members starting work, resulting in a repeat violation within 12 months.
Failure to obtain criminal record clearance for 2 staff members prior to starting work.
Failure to ensure a resident's reappraisal was updated after returning from the hospital.
Administrator failed to exhibit knowledge of applicable laws, rules, and regulations resulting in serious violations posing immediate health, safety, and personal rights risks.
Report Facts
Staff members not associated to roster: 4
Staff members without criminal record clearance: 2
Facility capacity: 214
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Golden | Vice President of Operations | Present at non-compliance conference and report review |
| Joel Goldman | Legal Council | Present at non-compliance conference and report review |
| Teri Moore-Showalter | Vice President of Care | Present at non-compliance conference and report review |
| Erika Hughes | Regional Director of Health Services | Present at non-compliance conference and report review |
| Jocelyne Bailon | Garden House Director | Present at non-compliance conference and report review |
| Nelson Rodrigues | Administrator | Named in deficiencies and noted as current Administrator with last day 06/14/2024 |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 214
Deficiencies: 1
Date: Jun 12, 2024
Visit Reason
The visit was an unannounced case management - deficiencies inspection conducted due to a violation observed during a complaint investigation regarding staff criminal record clearance.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Staff member (S1) worked at the facility without obtaining a criminal record clearance prior to starting work.
Report Facts
Civil penalty amount: 500
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Golden | Vice President of Operations | Met during inspection and report review |
| Kippie Castronovo | General Manager | Met during inspection and report review |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sarah Yip | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 214
Deficiencies: 1
Date: May 29, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to report the resident (R1)'s death and incident to the department within 24 hours as required.
Report Facts
Deficiency count: 1
Plan of Correction Due Date: May 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the case management - incident visit and authored the report. |
| Kippie Castronovo | General Manager | Met with Licensing Program Analyst during the visit and was involved in the discussion of findings. |
| Nelson Rodrigues | Administrator/Director | Named as facility administrator/director. |
| Sarah Yip | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 214
Deficiencies: 0
Date: May 29, 2024
Visit Reason
The visit was an unannounced case management - incident inspection conducted to review a resident's records and investigate a reported incident.
Complaint Details
The visit was triggered by a case management incident. The investigation is pending and no substantiation status is provided.
Findings
No deficiencies were cited during the visit per California Code of Regulations, Title 22. The case management visit is pending further investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the case management - incident visit. |
| Kippie Castronovo | General Manager | Met with Licensing Program Analyst during the visit and reviewed the report. |
| Nelson Rodrigues | Administrator | Named as facility administrator. |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 214
Deficiencies: 3
Date: Jan 16, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-08-28 alleging that a resident was found on the floor covered with ants and was severely neglected resulting in injuries after a fall.
Complaint Details
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.
Findings
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.
Deficiencies (3)
The licensee did not ensure resident (R1) was checked regularly for 72 hours after hospital discharge, resulting in injuries from a fall and neglect.
The licensee did not ensure resident (R1) was accorded a healthful and comfortable accommodation due to being found on the floor with ants on the resident's body.
The pre-admission appraisal was not updated accurately to document changes in resident (R1)'s condition after hospital discharge.
Report Facts
Capacity: 214
Census: 145
Civil penalty: 500
Plan of Correction Due Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Sarah Yip | Licensing Program Manager | Oversaw the complaint investigation |
| Kippie Castronovo | Interim General Manager | Facility representative met during investigation and report review |
| Nelson Rodrigues | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 214
Deficiencies: 0
Date: Jan 16, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging that the facility allowed unauthorized visitors to see resident R1 between January 2021 and June 2021.
Complaint Details
Complaint control number 26-AS-20220404161647 involved an allegation that the facility allowed unauthorized visitors. The allegation was investigated through interviews, record reviews, and observations and was found to be unfounded.
Findings
The investigation found no evidence that unauthorized visitors were allowed. Interviews and record reviews showed that resident R1 consented to visits from relatives, and there were no restraining orders or documentation restricting visitations. The allegation was determined to be unfounded.
Report Facts
Capacity: 214
Census: 145
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kim Golden | Executive Director | Met with Licensing Program Analyst during investigation |
| Diane Atkinson | Administrator | Interviewed during the investigation |
| Sarah Yip | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Capacity: 214
Deficiencies: 0
Date: Dec 15, 2023
Visit Reason
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kippie Castronovo | Interim General Manager | Met with Licensing Program Analyst during the visit and signed the amended LIC809-D. |
| Christine Dolores | Licensing Program Analyst | Conducted the unannounced case management visit and delivered the amended LIC809-D. |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 214
Deficiencies: 0
Date: Nov 9, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging that facility staff did not seek medical attention for a resident in a timely manner.
Complaint Details
The complaint alleged that facility staff did not seek medical attention for resident R1 in a timely manner due to pain from bunions. The allegation was investigated and found to be unfounded based on staff interviews, witness statements, and record review.
Findings
The investigation found no evidence to support the allegation. Staff interviews and record reviews indicated the resident did not complain of pain and there was no indication of medical concerns related to the resident's feet or bunions. The allegation was determined to be unfounded.
Report Facts
Capacity: 214
Census: 142
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Jocelyn Bailon | Garden House Director | Met with Licensing Program Analyst during investigation |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager on report |
| Nelson Rodrigues | Administrator | Facility Administrator |
Inspection Report
Complaint Investigation
Capacity: 214
Deficiencies: 1
Date: Jan 31, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff hit a resident in care.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Residents in all residential care facilities for the elderly shall have the right to be free from punishment, humiliation, intimidation, abuse, or other punitive actions. This requirement was not met as evidenced by staff kneed a resident causing harm.
Report Facts
Facility capacity: 214
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nelson Rodrigues | Executive Director | Met with Licensing Program Analyst during investigation and involved in plan of correction |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Sarah Yip | Licensing Program Manager | Oversaw complaint investigation and deficiency citation |
Inspection Report
Census: 151
Capacity: 214
Deficiencies: 0
Date: Jan 31, 2023
Visit Reason
The visit was conducted to deliver an immediate exclusion letter to exclude an employee (S1) at the facility.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nelson Rodrigues | Executive Director | Met with Licensing Program Analyst during the visit and received the immediate exclusion letter. |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 214
Deficiencies: 1
Date: Jan 31, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to request a transfer of a criminal record clearance for staff S1 and S2 prior to working at the facility.
Report Facts
Civil penalty amount: 3000
Civil penalty amount: 3000
Capacity: 214
Census: 151
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nelson Rodrigues | Executive Director | Met with Licensing Program Analyst during inspection and involved in plan of correction |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sarah Yip | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 214
Deficiencies: 2
Date: Dec 8, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Staff (S1) working at the facility without fingerprint clearance.
Staff (S2) working at the facility without proper association.
Report Facts
Civil penalty amount: 500
Civil penalty amount: 500
Number of days staff worked without clearance/association: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Atkinson | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Kippie Castronovo | Business Officer Director | Confirmed staff employment details during investigation |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sarah Yip | Licensing Program Manager | Supervisor overseeing the investigation |
Inspection Report
Census: 156
Capacity: 214
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
The visit was conducted to deliver an immediate exclusion letter to exclude an employee (S1) at the facility.
Findings
An immediate exclusion letter and declaration of service were handed to the Executive Director during the visit. The report was reviewed with the Executive Director and a copy was provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Atkinson | Executive Director | Met during the visit and received the immediate exclusion letter. |
| Christine Dolores | Licensing Program Analyst | Conducted the unannounced Case Management - Other visit. |
| Sarah Yip | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 150
Capacity: 214
Deficiencies: 1
Date: Sep 19, 2022
Visit Reason
The visit was an unannounced annual inspection focusing on infection control at the facility.
Findings
The inspection found that the facility was generally compliant with infection control practices, including PPE use, symptom screening, and cleanliness. However, a deficiency was cited for having multiple sharp gardening tools and toxins accessible in the community garden to persons with dementia, posing an immediate health and safety risk.
Deficiencies (1)
Multiple sharp gardening tools and toxins were accessible in the community garden to persons with dementia, violating storage requirements.
Report Facts
POC Due Date: Sep 20, 2022
Census: 150
Total Capacity: 214
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Atkinson | Executive Director | Met during inspection and reviewed report |
| Richard Padilla | Resident Service Director | Met during inspection and toured facility |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection |
| Sarah Yip | Licensing Program Manager | Supervisor of inspection |
Inspection Report
Complaint Investigation
Capacity: 214
Deficiencies: 0
Date: Apr 13, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 214
Residents interviewed: 5
Staff interviewed: 4
Dates of document review: Documents reviewed from 2021-10-15 to 2022-03-16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Diane Atkinson | Executive Director | Facility administrator met during the investigation and reviewed the report |
| Jackie Jin | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Original Licensing
Census: 142
Capacity: 214
Deficiencies: 0
Date: Sep 7, 2021
Visit Reason
Unannounced pre-licensing continuation visit to evaluate the facility's readiness for licensing.
Findings
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.
Report Facts
Resident files reviewed: 13
Staff files reviewed: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Atkinson | Administrator | Facility administrator met during the inspection and mentioned as having been a facility administrator since 11/1986. |
| Jackie Jin | Licensing Program Manager | Conducted the inspection along with the Licensing Program Analyst. |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection along with the Licensing Program Manager. |
Inspection Report
Original Licensing
Census: 139
Capacity: 214
Deficiencies: 0
Date: Aug 20, 2021
Visit Reason
The visit was an unannounced pre-licensing inspection conducted to evaluate the facility for licensing approval.
Findings
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.
Report Facts
Fire clearance capacity: 214
Perishables observed: 2
Nonperishables observed: 7
Refrigerator temperature: 37
Freezer temperature: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Atkinson | Administrator | Met with during pre-licensing visit and report reviewed with |
| Jackie Jin | Licensing Program Manager | Conducted pre-licensing visit |
| Christine Dolores | Licensing Program Analyst | Conducted pre-licensing visit |
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