435202159-11-29-2022-26-AS-SYIP-CLVNCS-20221207092113

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202159
Report Date: 11/29/2022
Date Signed: 11/29/2022 03:00:33 PM

Unsubstantiated

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
03/02/2021 and conducted by Evaluator Christine Dolores

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210302090324

FACILITY NAME:	MERRILL GARDENS AT WILLOW GLEN		FACILITY NUMBER:	435202159
ADMINISTRATOR:	GRACE KOMASAKA		FACILITY TYPE:	740
ADDRESS:	1420 CURCI DR		TELEPHONE:	(408) 283-0941
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95126
CAPACITY:	0	CENSUS: 84	DATE:	11/29/2022
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Corinne Gies		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Facility staff caused injury to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding for the above allegation. LPA met with General Manager, Corinne Gies.

On 03/03/2021, the initial complaint investigation was conducted by LPA Yatfai Eric Ng. Between 03/03/2021 - 05/26/2021, documents were obtained to include the facility staff roster, resident roster, physician’s reports, and medical records. On 11/29/2022, LPA Dolores obtained additional physician's reports and needs and services plans.

In February 2021, it was alleged resident (R1) was shoved into a wall by a staff who weighed 400 pounds causing injuries.

On 05/26/2021, 9 residents were interviewed. 5 out of 9 residents state to not observe a staff member at the facility who weighs 400 pounds. Based on interview, 8 out of 9 residents did not obtain any injury from staff nor witnessed any staff causing injury to another resident. See LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210302090324

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: 435202159
	VISIT DATE: 11/29/2022

NARRATIVE

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On 05/26/2021, 1 staff member was interviewed. S1 denied staff causing injury to a resident.

Based on interview and record review, the alleged suspected abuser had resigned from the facility.

Based on record review, R1 is diagnosed with a mild cognitive impairment and other medical disorders relating to delusions and hallucinations.

The review of the police report record determined no abuse had occurred.

The Department has investigated the above allegation. Based on interviews and record review the Department has determined that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with General Manager, Corinne Gies and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC9099 (FAS) - (06/04)

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