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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 03:21:56 PM

Substantiated


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:
03:30 PM
ALLEGATION(S):
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Facility did not notify CCL within 5 days of the initiation of hospice care.
INVESTIGATION FINDINGS:
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On 12/01/25 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced complaint investigation visit to deliver findings and met with Ida Gemignani-Stearns. LPA announced the purpose of the visit.

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

During the investigation the department interviewed 5 staff. 5 out of 5 staff stated that the department reports special incidents to the department within 7 days and notification of hospice services within 5 days. 1 out of 5 staff stated that the facility had issues with their fax machine in the month of December 2024 and January 2025 where faxes were taking up to an hour to transmit. The facility could not provide documentation informing the department of R1s admittance to Hospice services on 09/06/24.

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Substantiated
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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On 12/01/25 the department completed its investigation and determined the facility did not submit a hospice notification for R1 who began hospice services on 09/06/24.

Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Citations noted today. Please see LIC9099-D. Exit interview was conducted with Ida Gemignani-Stearns, ADM. A copy of the report and appeals rights were 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: 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2025
Section Cited
CCR
87632(d)(2)
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87632 Hospice Care Waiver (d)(2) The licensee shall notify the Department... initiation of hospice care services... five working days of admitting a resident already receiving hospice care services...
This requirement was not met as evidenced by;
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ADM stated she will send a letter of understanding regarding the hospice waiver stipualtions, such as notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days...
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Based on record review and interview, facility ADM stated she did not notifiy the deparment of the initiation of hospice care services for R1. This poses/posed a potential health, safety or personal rights risk to persons in care.
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admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice agency.
ADM stated she will send the plan of correction by POC date 12/12/25
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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