<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202159
Report Date: 09/03/2021
Date Signed: 09/30/2021 10:59:15 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:KIM GOLDENFACILITY TYPE:
740
ADDRESS:1420 CURCI DRTELEPHONE:
(408) 283-0941
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:150CENSUS: 76DATE:
09/03/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Carina BuremenTIME COMPLETED:
04:01 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Manager (LPM) Sarah Yip, Licensing Program Analyst (LPA) Yatfai Eric Ng partnered with Health Facilities Evaluator Nurse (HFEN) Helen Shi from the California Department of Public Health, conducted a Case Management - COVID-19 - tele-visit via FaceTime, to provide a technical assistance to prevent and to mitigate the spread of COVID-19 at the facility. LPM, LPA, and HFEN met with the Inspired Connections Program Director (ICPD) Carina Buremen.

Assisted living and memory care unit were toured. The facility was observed to be in sanitary condition. One centralized entrance was utilized at the facility. A screening station with thermometer, hand sanitizer, COVID-19 questionnaire, and sign-in sheet was present. All staff and visitors must check in before entering the facility. Partitions were installed on reception counter and tables in reception area. There were signs reminding everyone to practice social distance and to increase COVID-19 awareness throughout the facility. Hand sanitizers were readily available in different areas. In the dining room, tables were at least 6 feet apart. There were only 2 chairs in each table in the dining room.

2 public restrooms were toured. Soap, paper towels, and trash bins with lids were available. Hand washing signs were posted. There was a designated visitation area for the visitors in the backyard to promote outdoor visitation.
Page 1 of 2
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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
VISIT DATE: 09/03/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A COVID-19 isolation room was toured. There were donning and doffing signs posted. Gloves, gowns, N95 masks, sanitizer, etc. were readily available for staff to use. Only designated staff, who had N95 fit testing conducted, would go inside the isolation room. Those designated staff would only take their breaks outside to avoid any contact with regular staff.

There were COVID-19 signs posted in staff break room. Disinfectant was available for staff to use before and after the break room was used. All staff in the facility were observed to be wearing masks.

The current visitation guideline and practices from the Department were discussed with ICPD. The following infection control practices were suggested:
  1. To replace uncovered trash bin in staff restroom with trash bin with lid.
  2. To remind staff, residents, and visitors to keep their masks on in public areas.
  3. To use an unoccupied resident room as a break room for staff.

ICPD stated the recommendations would be reviewed.

No deficiency cited during visit. This report was emailed to ICPD to review and to obtain a signature.
Page 2 of 2
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2