435202807-7-11-2025-26-AS-CKAI-DQS3F2-20260128171202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 07/11/2025
Date Signed: 07/11/2025 09:25:05 AM

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
06/17/2025 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20250617101735

FACILITY NAME:	MERRILL GARDENS AT WILLOW GLEN		FACILITY NUMBER:	435202807
ADMINISTRATOR:	GOLDEN, KIM		FACILITY TYPE:	740
ADDRESS:	1420 CURCI DRIVE		TELEPHONE:	(408) 283-0941
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95126
CAPACITY:	150	CENSUS:	DATE:	07/11/2025
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Ida Gemignani-Stearns		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff physically abused resident, resulting in resident experiencing bruising
Staff verbally abused client

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator Ida Gemignani-Stearns. On 06/17/2025, the department received a complaint with the above allegations. On 06/17/2025, LPA Marrufo conducted an initial complaint investigation visit. On 06/19/2025, LPA Marrufo conducted an additional complaint investigation visit.

On 06/13/2025, the facility submitted an Unusual Incident Report (IR) to the department. The IR stated that on 06/13/2025 at 4:00 PM, resident R1 reported to the facility Residential Care Director that on 06/11/2025 at 8:30 AM, staff S1 stated told R1 to “Shut up,” grabbed R1 by R1’s shirt collar and pulled R1 out of bed and into R1’s wheelchair, and then pushed R1 against the bathroom wall, causing R1 to experience pain to R1’s left shoulder. R1 declined to have R1’s shoulder injury evaluated.

See LIC9099-C pages for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

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 3

Control Number 26-AS-20250617101735

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: 07/11/2025

NARRATIVE

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During visit on 06/17/2025, LPA Marrufo conducted interviews with R1, R2 (R1’s spouse), and S1.

R1 stated that S1 came into R1’s living unit around 8:20 AM on the morning of the incident. R1 stated that S1 grabbed R1 by the collar, lifted R1 from the bed, and pushed R1 into R1’s wheelchair. R1 stated to have told S1, “Stop it! Don’t do that,” while S1 was grabbing R1 by the collar. R1 stated S1 took R1 to the bathroom and put R1 on the toilet. R1 stated S1 picked up R1 by R1’s shirt and pushed R1 against the bathroom wall, hitting the grab bar that is mounted against the wall. R1 stated S1 was standing holding up R1 against the wall while standing behind R1. R1 stated that S1 has pushed R1 against the wall on other occasions and has told S1 not to push R1. R1 stated to have not reported any of S1’s prior behaviors to facility management. R1 stated S1 moved R1 into the kitchen for breakfast, and then S1 left the living unit.

R2 stated that S1 had already left the living unit when R1 told R2 that S1 handled R1 roughly. R2 stated to have been in the other living room across from the bedroom when the incident occurred. R2 stated to have not heard anything that happened. R2 stated that when R1 was in the kitchen and S1 had left, R1 told R2 that S1 was very rude and grabbed R1 by the shirt. R2 stated to have seen the bruise on R1. R2 stated that R1 had a red bruise on the neck by the shoulder. R2 stated the bruise was about four finger spaces long.

During interview, LPA Marrufo observed R1 and did not see any bruising on R1’s neck.

During interview, S1 stated to have entered R1 and R2’s living unit between 8:00 AM to 10:00 AM on the morning of the incident. S1 stated that R1 has an injured arm, so S1 transferred S1 from the bed to the wheelchair by putting one arm under R1’s non-injured shoulder and another arm around R1’s waist to avoid injuring R1’s shoulder. S1 denied grabbing R1 by the shirt collar. S1 stated to have not pushed R1 against the bathroom wall. S1 stated to have not told R1 to “shut up.” S1 stated to have told R2 to be quiet but does not remember the exact words S1 used towards R2.

LPA Marrufo conducted a telephone interview with R2 on 06/27/2025. R2 stated that S1 has never told R2 to “shut up” or be quiet.

Page 2 of 3.

SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20250617101735

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: 07/11/2025

NARRATIVE

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Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No deficiencies were cited under California Code of Regulations Title 22.

This report was reviewed with Administrator Ida Gemignani-Stearns and a copy of this report was provided.

Page 3 of 3.

SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

LIC9099 (FAS) - (06/04)

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