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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202159
Report Date: 05/26/2021
Date Signed: 05/28/2021 01:29:20 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:MELISSA G HERNANDEZFACILITY TYPE:
740
ADDRESS:1420 CURCI DRTELEPHONE:
(408) 283-0941
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:150CENSUS: 77DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:35 PM
MET WITH:Melissa HernandezTIME COMPLETED:
06:05 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Maintenance Director (MD) Morgan Standley and General Manager (GM) Melissa Hernandez.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, sign in sheet, and COVID-19 questionnaire were present at the entrance. Hand sanitizing stations were present. LPA toured the facility with MD.

The facility was observed to be in sanitary condition. All staff members were observed to be wearing masks. Tables in the dining rooms were at least 6 feet apart from each other. Residents were at least 6 feet apart when they were exercising. During visit, the facility was conducting a COVID-19 surveillance testing for staff members.

All restrooms observed to be adequately stocked with paper towels and hand soap.

Facility was observed to have adequate supply of PPE in the storage area.

No deficiency cited during visit. However, advisory notes were issued. See LIC 9102.

This report was reviewed with GM and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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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