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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202159
Report Date: 07/21/2021
Date Signed: 07/22/2021 09:54:47 AM

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: 75DATE:
07/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:25 PM
MET WITH:Melissa HernandezTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced case management visit and met with the General Manager (GM) Melissa Hernandez.

The purpose of the visit was to gather additional information as Community Care Licensing Department (CCLD) received a report from a government agency that the facility had a COVID-19 positive case in June 2021. However, CCLD did not receive such report in June 2021 within 24 hours according to the requirement stated in the Regulation.

LPA interviewed GM. LPA learned that the staff only reported to the local Department of Public Health but the CCLD.

A deficiency was cited during visit. See 809-D for additional information.

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

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 GLEN
FACILITY NUMBER: 435202159
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2021
Section Cited

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87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including… (2) Occurrences, such as epidemic outbreaks… which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the
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licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by: Based on interviews, the Administrator admitted the COVID-19 positive case in June was not reported to the Department. This posed a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2021
LIC809 (FAS) - (06/04)
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