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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 12/01/2025
Date Signed: 12/01/2025 03:34:35 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
10/11/2024 and conducted by Evaluator Marcela Yanez
COMPLAINT CONTROL NUMBER: 26-AS-20241011112030
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: DATE:
12/01/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ida Gemignani-Stearns, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff are not treating residents with dignity and respect.
Facility staff did not to seek timely medical attention to a resident who sustained an injury resulted in death.
Facility medication cart was left unattended and accessible to residents.
Facility staff did not adhere to residents' medication as per physician's order.
Facility did not submit an incident/death report to licensing.
INVESTIGATION FINDINGS:
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On 12/01/25 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced complaint investigation visit to deliver the findings. LPA announced the purpose of the visit and met with Administrator (ADM) Ida Gemignani-Stearns.

On 10/11/24 the department received a complaint with the above allegations.

On 10/14/24 LPA Marrufo conducted a 10-day initial complaint investigation visit and obtained copies of pertinent resident files, staff, and facility records.

On 07/11/25 LPA Yanez conducted a follow-up complaint investigation visit. LPA interviewed ADM, 3 staff and 5 residents.

Page 1 of 3
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2025
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-20241011112030
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: 12/01/2025
NARRATIVE
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Page 2 of 2

LPA obtained documents including but not limited to death report and incident report for 1 resident and reviewed Centrally Stored Medication Records for 3 residents.

On 09/29/25 LPA Yanez conducted a follow up complaint investigation visit and interviewed 1 staff and obtained pertinent resident documentation.

On 10/10/25 LPA Yanez conducted a follow up complaint investigation visit and interviewed 5 additional residents.

During the investigation the department interviewed 10 Residents (R1-R10) and 5 Staff (S1-S5). 9 out of 10 residents stated the facility staff have not been disrespectful or rude and have always treated them with dignity and respect. 1 out of 10 residents stated that the previous facility general manager was difficult to work with.

During the investigation Resident (R1s) death report was reviewed and determined resident passed away from underline ailments and the death certificate states that the residents time interval between the onset and death was listed as years.

7 out of 7 staff stated they have not seen the medication cart unattended, the only time is when a Med-Tech is handing out medication, but it is locked when left unattended.

7 out of 10 residents stated that they get there medication on time and according to doctors order. 3 out of 10 resident stated they administer their own medication.

During visit LPA Yanez observed staff administering medication to residents and 2 of 2 residents visited the Medication Room to get there noon medication, and Med Tech stated residents are diligent when its time for their medication to be administered.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20241011112030
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: 12/01/2025
NARRATIVE
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Page 3 of 3

LPA audited 6 residents Centrally Stored Medication Record and found all medication was administered according to doctors order.

During the investigation the department reviewed an incident report with R1s fall dated 10/01/24 and fax cover sheet stating 3 pages that were faxed to the department on 10/01/24.

On 12/01/25 the department has completed its investigation and found the above allegations Based on these observations, the above allegations are UNSUBSTANTIATED.

Although the 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 at this time.

This report was reviewed with ADM Ida Gemignani-Stearns and a copy of the report was provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3