Merrill Gardens at Campbell

Allegation investigated: Facility did not ensure resident was observed regularly Facility did not provide eviction letter Facility did not allow 1:1 private care for resident

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to deliver the findings of a complaint received by the Department on 6/19/2025. LPA met with General Manager (GM) Alex Den. LPA stated the purpose of the visit. On 6/25/2025 and 10/14/2025 complaint investigation visits were conducted. On 6/25/2025, LPA Tarin interviewed Reporting Party (RP). RP states the facility is not assessing Resident (referred to as R1). RP states the facility did not know R1 has neurocognitive disorder. RP states R1 had an incident that caused water damage to the facility in February 2025, and the facility requested an updated physician's report for R1 due to this incident. Page 1 of 3 Unsubstantiated LPA interviewed General Manger (GM) Alex Den. GM states R1 was reassessed by the facility on 2/3/2025 when R1 was observed to be confused while walking around the facility. GM states R1 also had an incident that caused water damage to the facility in February 2025. LPA interviewed 1 Staff (S1). S1 states he/she reassessed R1 on 2/3/2025 when R1 was observed to be confused while walking in the facility, an observed change of condition. S1 states extra support for R1 to include reminders, redirection and staff checking on R1 every 2 hours began on 2/9/2025. LPA interviewed 11 Residents (R1 to R11). 11 Out of 11 residents stated they have no issues or concerns with the care they are receiving. Based on review of documentation, R1’s physician’s reports are dated 4/21/2016, with R1’s mental condition listed as able to follow instructions, able to communicate needs, able to leave unassisted. No diagnosis or medical conditions listed. R1’s physician’s report dated 2/6/2025 states R1’s has diagnosis of major neurocognitive disorder, and mild cognitive impairment. Review of an additional medical assessment of R1 was conducted on 3/27/2025, which noted R1 to have mixed neurocognitive disorder. Facility did not provide eviction letter It has been alleged by the RP that the facility did not provide an eviction letter to R1. RP states the facility verbally tried evict R1 on 6/18/2025, if R1 did not move into the memory care within the facility. RP states he/she requested the eviction in writing, and the facility did not provide an eviction notice. LPA interviewed GM. GM states he/she met with RP and had a 'chat' and a recommendation was made for R1 to move into memory care. GM states R1 was not being evicted. LPA interviewed S1. S1 states there was never any eviction for R1, only a recommendation for R1 to move into memory care, which was shared with RP during a care conference. LPA interviewed 11 Residents (R1 to R11). 11 Out of 11 residents stated they have no issues or concerns with the care they are receiving. Page 2 of 3 Facility did not allow 1:1 private care for resident It has been alleged by the RP that the facility did not allow 1:1 care for R1 in February 2025 when R1 caused water damaged at the facility. RP states he/she was told by GM that 1:1 care was not allowed. LPA interviewed GM. GM states R1 is receiving additional support from staff after the incident of water damage by R1 in February 2025. GM states RP did not allow recommended 1:1 care for R1 on multiple occasions. GM did not remember dates of this incident. LPA interviewed S1. S1 states R1 has been provided additional staff support since 2/9/2025 to include reminders, redirection and staff checking on R1 every 2 hours. S1 did not provided additional information regarding 1:1 care for R1. LPA interviewed 11 Residents (R1 to R11). 11 Out of 11 residents stated they have no issues or concerns with the care they are receiving. Based on review of documentation, R1 has been receiving additional staff support since 2/9/2025. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was providedthe state’s words, verbatim · CDSS document, Jan 2, 2026 · control 26-AS-20250619095310

Type of visit: POC

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Plan of Corrections visit for a deficiency cited on 10/14/2025. LPA met with General Manager (GM) Alex Den. LPA stated the purpose of the visit. On 10/14/2025 during the facility's annual inspection, LPA Tarin observed a Clorox toilet bowl cleaner in a storage cabinet above the toilet in Resident R10's room in Garden House (Memory Care). A Type A deficiency was issued with a Plan of Correction due date of 10/15/2025. GM submitted POC by POC due date 10/15/2025. During today's visit, LPA toured 5 random resident rooms in Garden House and did not observe disinfectants or cleaning solutions which could pose a danger to residents in care. A Letter of Deficiency Citations Cleared was provided to GM during today's visit. No deficiencies were cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with GM Alex Den and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 21, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with General Manager (GM) Alex Den. LPA stated the purpose of the visit. LPA toured the interior and exterior of the facility with GM to include the kitchen, resident rooms, dining room, bathrooms. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed refrigerator temperature a 40 degrees F and Freezer at -6 degrees F. The facility was equipped with smoke and carbon monoxide detectors. The facility fire system was last inspected by a third party vendor on 7/24/2025 and passed inspection. Fire extinguishers were last serviced on 4/28/2025. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was conducted on 9/24/2025. LPA toured 10 random resident bedrooms. All 10 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 6 bathrooms. All 6 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature with a range from 107.2 F to 116.6 F. Page 1 of 2 During tour of R10's room in Garden House (Memory Care), LPA observed a Clorox toilet bowl cleaner in a storage cabinet above the toilet. Based on review of R10's physicians report dated 6/26/2025, R10 has neurocognitive disorder. R10 also has a CA Toxic Chemical Storage notice dated 6/17/2025 and signed by R10s physician, stating R10 should not have 'bleach and like items' stored in his/her apartment. GM states she does not why there was a Clorox toilet bowl cleaner in R10's bathroom cabinet. A deficiency is being issued. LPA reviewed 5 resident records. LPA reviewed 5 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA reviewed 5 staff records. A deficiency was cited during today's visit per California Code of Regulations Title 22. See LIC809-D for more information. An exit interview was conducted with General Manger Alex Den and a signed copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 14, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a case management to follow up on deficiencies that were cited on 10/28/2024. LPA Tarin met with Administrator (ADM) Bradley Burgoyne. On 10/28/2024, LPA Tarin conducted the facility's annual inspection. During resident record review, LPA Tarin observed Resident records for R2 and R3, did not contain updated physician's reports. Resident R2 and R3 physician's reports were not updated within the year. R2 and R3 have neurocognitive disorder. During staff record review, LPA Tarin observed 3 out of 8 staff (S2, S6, and S7) records did not contain CPR/first aid training. During today's visit, LPA Tarin reviewed documentation for S2 and S7 to have completed CPR/First Aid training on 10/28/2024. ADM stated S6 has completed the CPR/First Aid training, but has not obtained the certificate. ADM states the facility will email a copy of S6's CPR/First Aid training once it is obtained. LPA Tarin reviewed updated physician's reports for R2, updated on 09/24/2024. ADM states R3 had a video appointment with his/her physician on 11/7/2024, and is awaiting a copy of the updated physician's report. ADM states the facility will email a copy of R3's updated physician's report once it is received. LPA Tarin cleared the deficiencies cited on 10/28/2024 during today's visit. A Letter of Deficiency Citations Cleared was printed and provided to ADM. No deficiencies were cited during todays visit. A copy of this report was provided to ADM Bradley Burgoyne.the state’s words, verbatim · CDSS document, Nov 8, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection visit at 9:15 AM and met with Administrator, Bradley Burgoyne. LPA toured the facility inside and out with the Administrator to include the resident dining room, kitchen, resident bedrooms, bathrooms, and exterior. Facility temperature maintained between 71 to 72 degrees F. Facility staff are fingerprint cleared and associated to facility. All emergency exits were observed to be clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature maintained at 35 degrees F and freezer maintained at -1 degrees F. The exterior of the facility was also inspected. No toxins, chemicals or items that can pose a danger to residents observed. LPA Tarin toured 7 resident bedrooms. 7 out of 7 resident bedrooms had functioning lights, storage space for personal belongings, clean bedding, a chair, lamp and dresser/table. LPA measured hot water temperature, with a range of 113.7 to 114.2 degrees F for 7 out of 7 resident bathrooms. The facility was equipped with smoke and carbon monoxide detectors, and last serviced on 10/24/2024. Fire extinguishers were last serviced on 04/23/2024. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake drill log was reviewed and drills are being conducted quarterly. The last fire drill was conducted on 09/24/2024. Facility has emergency disaster plan. LPA reviewed 7 residents Centrally Stored Medication and Destruction Records (CSMDR). LPA observed 7 out of 7 CSMDRs are complete with all medications accounted and documented. LPA observed the medication storage area was locked and inaccessible to residents in care. Please see LIC 809-C. LPA reviewed 7 resident records. LPA observed 5 out of 7 resident records as complete to include a physician's report,TB result, updated appraisal/needs and services plan, identification and emergency contact information, personal rights, and consent forms. Resident (R2 and R3) records did not contain updated physician's reports. Resident R2 and R3 physician's reports were not updated within the year. R2 and R3 have neurocognitive disorder. LPA advised Administrator to obtain updated physician's reports for Residents R2 and R3. LPA reviewed 8 staff records. LPA observed 8 out of 8 records to include fingerprint clearance, health screening, TB result, and personnel record. 3 out of 8 staff (S2, S6, and S7) records did not contain CPR/first aid training. LPA advised Administrator that staff who assist residents with personal activities of daily living shall receive appropriate training in CPR/first aid. Deficiencies were cited today per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Bradley Burgoyne. A copy of this report was provided to Administrator and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Oct 28, 2024

Allegation investigated: Facility staff pinched and slapped a resident's face.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Administrator (ADM) Bradley Burgoyne and Guest Service Director(GSD) Will Carter. On 11/03/2023, the Department received a complaint with the allegation that facility staff pinched and slapped a resident's face. On 11/9/2023, the Department conducted an initial investigation visit. LPA interviewed General Manger (GM), 5 staff, 4 residents, and a family member of resident. LPA requested LIC500 Personnel Report, resident roster, R1's physician report and Appraisal Needs and Service Plan. Continue on LIC9099-C. Page 1 of 3. Unsubstantiated Facility staff pinched and slapped a resident's face: The allegation is that facility staff S1 tried to feed resident R1 but R1 refused to be fed, and S1 pinched and slapped R1's face. On 11/9/2023, LPA interviewed Administrator (ADM) Bradley Burgoyns. ADM stated the incident is under investigation. ADM stated the facility is unable to substantiate it. But the internal investigation finding report is not finalized yet. ADM stated staff S1 is under suspension by the facility protocol. ADM stated resident R1 was evaluated immediately after he/she received the incident report. ADM stated R1 was observed without injury and without sign of abuse. LPA interviewed Memory Care Unit Director (MCD). MCD stated resident R1 eats meals by himself/herself. MCD stated staff S2, S3, and a private caregiver (PC) were on site during the incident. MCD stated he/she interviewed S2, S3 and PC. S2 and S3 stated they did not see S1 pinched and slapped R1's face. PC stated S1 pushed food to R1's mouth. MCD stated S1 reported to him/her that R1 refused the medication after retried during the incident time period. MCD stated he/she helped to administer medications to R1 after received S1's report. LPA interviewed staff S2 and S3. Both stated they were on site during the incident but did not see S1 pinched and slapped R1's face. LPA interviewed staff S4. S4 stated he/she did not see any incident that staff pinching and slapping resident in the facility. LPA interviewed staff S5. S5 stated he/she evaluated R1 for admission. S5 stated R1 has neurocognitive impairment. LPA interviewed S1 on the phone. S1 stated R1 eats meals by himself/herself. S1 stated he/she never feeds R1 food. S1 stated he/she tried to administer medications to R1 but R1 fused to take medication. S1 stated he/she reported to MCD and MCD was able to administer medications to R1. S1 stated he/she continued to administer medication to other residents after the incident. LAP interviewed resident R1. R1 has neurocognitive impairment. R1's answers were conflicting. LPA did not observe bruise, injury, sign of abuse on R1. LPA interviewed 3 residents (R2 - R4). 3 out 3 residents stated they never saw or heard staff pinching or slapping resident's face. Continue on LIC9099-C. Page 2 of 3. LPA interviewed R1's family member (FM). FM stated he/she visited R1 on the that day of the incident from 1:30PM to 3:00PM. He/she did not see any bruise, injury or sign of abuse on R1. FM stated R1 did not complain anything to him/her. Based on the review of R1' physician report dated 9/13/2023, R1 has neurocognitive impairment. On 9/30/2024, LPA interviewed Administrator (ADM). ADM stated the facility final internal investigation finding is unsubstantiated, meaning the facility cannot prove the incident did happen or did not happen. ADM stated the facility notified staff S1 on 11/10/2023 and S1 came back to work on 11/10/2023. ADM provided a copy of the facility internal investigation finding report. ADM stated S1 was working for the facility until 6/1/2024. ADM stated resident R1 still lives in the facility. Based on the review of R1's appraisal needs and service plan dated 1/25/2023, R1 has neurocognitive impairment. Based on the review of law enforcement task force report dated 11/09/2023, R1 was unable to answer the questions. No injury was observed on R1. Based on the interviews and records reviewed, no evidence to indicate that facility staff pinched and slapped a resident's face. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. This report was provided to review and for signature. A copy of this report was provided to ADM. Page 3 of 3.the state’s words, verbatim · CDSS document, Oct 8, 2024 · control 26-AS-20231103125657

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Incident visit and met with Bradley Burgoyne. The purpose of the visit was to follow up with an incident self-reported by the facility in which staff S1 was allegedly observed to have hit resident R1 on the back of the head. During visit, LPA Marrufo obtained resident records for R1 and training records for S1. Staff S1 was not present during visit and was not interviewed. During visit, LPA Marrufo conducted a wellness check and observation of R1. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Bradley Burgoyne and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 2, 2024