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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202807
Report Date: 12/04/2024
Date Signed: 12/04/2024 03:44:53 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/04/2024 03:44 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: 88DATE:
12/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Karen NickolaiTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Annual Continuation visit and met with Karen Nickolai, Administrator. The visit was a continuation of the Required 1 Year Annual Inspection that was started on 11/27/2024.

During visit on 11/27/2024, LPA Marrufo reviewed the resident medication records for residents R1-R8. The Centrally Stored Medication and Destruction Records for R3, R4, R5, R6, and R8 had prescription numbers that were incorrect.

LPA reviewed the resident records for R1-R8 and staff records for 8 staff and found them to be complete.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information.

This report was reviewed with Administrator Karen Nickolai and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/04/2024 03:44 PM - It Cannot Be Edited


Created By: David Marrufo On 12/04/2024 at 11:31 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MERRILL GARDENS AT WILLOW GLEN
FACILITY NUMBER: 435202807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/11/2024
Section Cited
CCR
87465(h)(6)(E)

1
2
3
4
5
6
7
87465(h)(6)(E) Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored
1
2
3
4
5
6
7
Licensee agrees to conduct in-service training with staff to ensure that staff correctly record the prescription numbers of resident medications in the Centrally Stored Medication Logs by POC Due Date. The Licensee agrees to submit copies of staff training records that include names of
8
9
10
11
12
13
14
prescription medications for each resident is maintained for at least one year and includes: (E) The prescription number and the name of the issuing pharmacy. This requirement was not met as evidenced by: Licensee did not ensure that 5 out of 8 reviewed Centrally Stored Medication Logs had correct presciption numbers, which poses a potential health risk for residents in care.
8
9
10
11
12
13
14
staff trained, dates of training, and names and qualifications of trainers to CCL by POC due date.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2