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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202159
Report Date: 08/11/2020
Date Signed: 08/12/2020 02:03:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MERRILL GARDENS AT WILLOW GLENFACILITY NUMBER:
435202159
ADMINISTRATOR:ANHAR, WILSONFACILITY TYPE:
740
ADDRESS:1420 CURCI DRTELEPHONE:
(408) 283-0941
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:150CENSUS: 74DATE:
08/11/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:08 PM
MET WITH:Grace KomasakaTIME COMPLETED:
03:17 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced case management - other tele-visit. Due to current Coronavirus pandemic (COVID-19) situation, LPA virtually met with the Administrator (ADM) Grace Komasaka via telephone.

The purpose of the visit was to gather additional information as Community Care Licensing Department received a concern from the public that the facility might terminate a resident's residency if the resident would not follow the facility's COVID-19 policies.

During the shelter-in-place period of time due to COVID-19 pandemic, the facility asked the residents and their families to read, answer, and sign a questionnaire. The questionnaire asked the residents and their families to report any symptoms of COVID-19 and to report any activities that might increase the risk of contracting COVID-19. The questionnaire was drafted following the health department's guideline to mitigate the spread of COVID-19.

LPA obtained a copy of the questionnaire and a copy of admission agreement.

ADM stated she understood the elements before issuing any eviction notice to a resident. Tthe facility had not issued any eviction notice to the residents due to the COVID-19.

An advisory note (LIC 9102) was issued to the facility. No deficiency was cited during visit.

This report was emailed to ADM for reference and to obtain a signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020
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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