<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 11/07/2024
Date Signed: 11/07/2024 01:37:53 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
05/04/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220504133632
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: 88DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:General Manager, Karen NickolaiTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Staff children sleeping in the common area
-Facility plumbing in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On November 7, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unnannounced complaint visit to deliver the findings for the above allegations. LPA met with General Manager, Karen Nickolai and explained the purpose of the visit.

Regarding the allegation staff children are sleeping in the common area, according to the reporting party, Staff #1 (S1) brings her children to the facility several times a week and allows them to run around the facility and sleep on the ground in the common area. In addition, the reporting party indicated that S1 does not monitor her children and directs staff to watch them instead of caring for residents.

LPA interviewed the general manager, staff, and residents at the time. Based on interviews conducted, no children have ever slept at the facility and S1's children are only there for an hour or two, however would sit in S1’s office or the activity room. In addition, based on 5/5 residents interviewed, the children are not disruptive, and they are never in the way of residents. Resident interviewed also indicated that they have not observed any children running around or any children sleeping in the common areas. Futhermore, according to the staff interviewed, S1’s children do not sleep or run around at the facility, they usually sit in one place and color and it’s usually in the activity room or S1’s office. (continue to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cowan April
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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 2
Control Number 26-AS-20220504133632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MERRILL GARDENS AT WILLOW GLEN
FACILITY NUMBER: 435202807
VISIT DATE: 11/07/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation, facility plumbing is in disrepair, according to the reporting party, the memory care unit has a nonfunctional hand washing sink.

During the complaint investigation, LPA toured the facility, interviewed the general manager and staff at the time, and observed the hand washing sink in the memory care unit. According to interviews conducted, there may have been a cracked pipe, however the plumbing has been fixed and the sink is in good repair and working condition. During the complaint visit that was conducted on 5/12/22, LPA observed that the plumbing was repaired and plumbers were present at the facility during the visit. According to the general manager and interviewed staff, the facility has a maintenance director and a third-party contracting agency, Sener, that has been continuously working on the plumbing issues at the facility. Although there was a sink that was not functioning at the time due to remodeling, there were other sinks that were functioning at the facility and in specific, in the memory care unit and it was not affecting the daily operation of the facility.

Based on interviews conducted & observations, the department has determined that although the above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED.

Report is reviewed with the General Manager and copy is provided.
SUPERVISORS NAME: Cowan April
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2