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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 07/09/2024
Date Signed: 09/17/2024 05:19:14 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2022 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20220113142014
FACILITY NAME:MERRILL GARDENS AT WILLOW GLENFACILITY NUMBER:
435202807
ADMINISTRATOR:GOLDEN, KIMFACILITY TYPE:
740
ADDRESS:1420 CURCI DRIVETELEPHONE:
(408) 283-0941
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:150CENSUS: 94DATE:
07/09/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Karen Nickolai - GMTIME COMPLETED:
10:18 AM
ALLEGATION(S):
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Facility resident bedroom is not sanitary
Staff not responding to call button
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) conducted an unannounced investigation visit to delivered an amended investigation report and met with General Manger (GM) Karen Nickolai.

On 7/9/2024, Licensing Program Analyst (LPA) Steve Chang delivered the investigation findings report and met with General Manger (GM) Karen Nickolair.
On 01/13/2022, the Department received a complaint with the above allegations.
On 1/21/2022, the Department conducted an initial investigation visit and met with the prior General Manager (PGM) Corinne Gies. Due to the facility having COVID outbreak on 1/21/2022, LPA interviewed PGM at the facility backyard. LPA requested resident Physician's Report, Functional Capability Assessment, Admission Agreement, Housekeeping schedule, staff schedule, food menu, and emergency call log and maintenance log.

Continue on LIC9099-C. Page 1 of 6.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 26-AS-20220113142014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MERRILL GARDENS AT WILLOW GLEN
FACILITY NUMBER: 435202807
VISIT DATE: 07/09/2024
NARRATIVE
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This is an amended report, please see LIC9099 with the finding of "UNFOUNDED".

Continue on LIC9099-C. Page 2 of 6.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20220113142014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MERRILL GARDENS AT WILLOW GLEN
FACILITY NUMBER: 435202807
VISIT DATE: 07/09/2024
NARRATIVE
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Facility resident bedroom is not sanitary:
On 12/13/2023, LPA interviewed resident R1. R1 stated the facility housekeepers clean his/her room one time per week and take out the trash from his/her room. R1 stated he/she refuses the staff to come in to check on him/her to reduce the monthly payment charges. R1 stated he/she hires a private caregiver to come to his/her room 3 days per week to clean up the room and take out the trash.

LPA interviewed previous General Manager (GM1). GM1 stated R1 refused caregivers' checking on him/her. GM1 stated the caregivers were unable to enter the room to take out the trash in R1's room because R1 refused caregivers to come in R1's room to check R1. GM1 stated R1 refused the facility meals service to reduce the monthly payment. GM1 stated R1 eats meals in his/her room that scatters some food in the room. GM1 stated the facility provides housekeeping service one time per week. GM1 stated the facility caregivers take out trash when they visit the resident bedrooms.

LPA interviewed 3 residents. 2 out of 3 residents stated caregivers took out the trash when they visited the rooms. LPA inspected 3 resident rooms. 3 out of 3 resident rooms were observed without sign of cockroaches or bugs. 3 out of 3 residents stated they don't have cockroaches, bug, or ant in the rooms. LPA toured R1's room. R1's room was observed scattered with food in the room. The room was observed with signs of a few cockroaches. R1 stated he/she eats meals in the room. R1 stated he/she hires a private caregiver to clean the room.

On 5/23/2024, LPA interviewed 7 residents and inspected 7 resident rooms. 7 out of 7 residents stated the housekeepers clean the room at least one time per week. 7 out of 7 residents stated caregivers took out trash when they visited the rooms. 7 out of 7 residents stated they don't have cockroaches, bugs or ants in the rooms.

Based on the interviews and observation, R1 refused facility caregivers to enter his/her room and hires a private caregiver to clean his/her room. No other rooms were observed with sign of cockroaches, bugs or ants, and no other residents complained their rooms were not in sanitary condition.

Continue on LIC9099-C. Page 3 of 6.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20220113142014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MERRILL GARDENS AT WILLOW GLEN
FACILITY NUMBER: 435202807
VISIT DATE: 07/09/2024
NARRATIVE
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Staff not responding to call button:
On 1/21/2022, LPA interviewed prior General Manager (PGM). PGM stated the pendant bell alarm system and emergency pull alarm system in the bedroom both go to computer system and paging system. The staff and front desk will get notice immediately.

On 12/13/2023, LPA interviewed resident R1. R1 stated he/she refused the facility call button service to reduce the monthly payment. R1 stated he/she uses a third party company for call button service due to cheaper which is not connected to the facility.

R1 stated the caregivers come to his/her room within 10-15 minutes when he/she pulled the emergency call. R1 stated one time he waited for over one hour when he pulled the emergency call after he finishing toilet. R1 was unable to provide the exact date and time of the incident and was unsure if the emergency call was out of order.

LPA interviewed two residents. 2 out 2 residents stated the response time of call button is between 10 -20 minutes. Both stated the facility staff always responded to the call button.

LPA interviewed previous General Manager (GM1). GM1 stated R1 does not use the facility call button system. R1's call button system was connected to third party company and was not connected to the facility.

On 5/23/2024, LPA interviewed 8 residents. 1 out 8 stated he/she does not use the facility call button service. 2 out 8 stated the facility staff respond to the call button within 5 minutes. 4 out 8 residents stated the facility staff respond to the call button within 5 minutes. 1 out 8 resident stated the facility staff respond to the call button immediately, but one time it took 25 minutes.

Based on the document review, on 1/6/2022 around 10:06AM, R1's room Bath E-call was not working. Parts replaced was requested. No evidence to indicate if this incident matching R1's incident of long waiting for response for the emergency call.

Based on the interviews and documents reviewed, R1 refused the facility call button service to reduce the monthly payment and uses third party company's service. R1 stated usually the facility staff respond to the emergency within 10-15 minutes. Continue on LIC9099-C. Page 4 of 6.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20220113142014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MERRILL GARDENS AT WILLOW GLEN
FACILITY NUMBER: 435202807
VISIT DATE: 07/09/2024
NARRATIVE
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This is an amended report, please see the LIC9099 with the finding of "UNFOUNDED".

Continue on LIC9099-C. Page 5 of 6.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20220113142014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MERRILL GARDENS AT WILLOW GLEN
FACILITY NUMBER: 435202807
VISIT DATE: 07/09/2024
NARRATIVE
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The Department has investigated the above allegation. Based on interviews and observation, the department has found the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid, there is not a preponderance of evidence to show the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22.

Exit interview was conducted with GM. This report was provided to GM for signature. A copy of the report was provided to GM.



Page 6 of 6.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6