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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202807
Report Date: 11/27/2024
Date Signed: 11/27/2024 03:14:09 PM

Document Has Been Signed on 11/27/2024 03:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 GLENFACILITY NUMBER:
435202807
ADMINISTRATOR/
DIRECTOR:
GOLDEN, KIMFACILITY TYPE:
740
ADDRESS:1420 CURCI DRIVETELEPHONE:
(408) 283-0941
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY: 150CENSUS: DATE:
11/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Karen NikolaiTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Karen Nikolai, Administrator.

During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days.

LPA toured the outside area and found it to be clear of obstructions.

LPA toured two out of two resident hallway bathrooms and found each bathroom had available soap, paper towels, and functioning lights. LPA tested the water temperature in the sinks of both bathrooms and found the temperatures to be at 105 F and 109 F.

LPA toured 8 resident living units and found each living unit had available bedding and clothing storage areas. The water temperatures in the bathroom sinks measured between 105 F to 111 F.

Due to time constraints, the annual inspection will need to be continued at a further date.

No deficiencies were cited at this time as per California Code of Regulations Title 22 at this time.

This report was reviewed with Karen Nikolai, Administrator, and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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