435202159-11-15-2024-26-AS-KHOS-DBTT4J-20241210132357

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202159
Report Date: 11/15/2024
Date Signed: 11/15/2024 12:22:59 PM

Substantiated

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
07/12/2021 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 26-AS-20210712090342

FACILITY NAME:	MERRILL GARDENS AT WILLOW GLEN		FACILITY NUMBER:	435202159
ADMINISTRATOR:	MELISSA G HERNANDEZ		FACILITY TYPE:	740
ADDRESS:	1420 CURCI DR		TELEPHONE:	(408) 283-0941
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95126
CAPACITY:	0	CENSUS: 90	DATE:	11/15/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	General Manager, Karen Nickolai		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident services not being provided due to not enough staff

INVESTIGATION FINDINGS:

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On 11/15/2024, Licensing Program Analyst (LPA) Tobola and Jain arrived unannounced for the purpose of delivering complaint investigation and was greeted by General Manager, Karen Nickolai. The Department conducted tour of the facility, interviewed multiple staff and residents, reviewed facility records and made observations during the course of the investigation.

Complaint alleges resident services not being provided due to not enough staff. Allegation indicates that resident (R1) not provided sufficient showering based on care plan and provided dressing due to staff shortages on July 10 & 11, 2021. Based upon R1’s needs & service plan, R1 does not require a 2 person assist when provided ADL’s including showering/bathing or dressing. Upon review of staff time sheets from July 10 & 11, 2021 LPA found that there were a minimum of three staff on duty during these dates.

Continued onto LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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-20210712090342

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: 11/15/2024

NARRATIVE

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However, allegation also indicates that R1 waited 30-60 minutes for staff response times from pendant calls. However, based on review of Stravos Daily Zone Activity Report, indicating staff call response times; it was found that in July 2021, there were 83 total responses to emergency or pendant calls that were over 30 minutes in response time. In addition, 25 of the emergency or pendant calls were over 1 hour, reaching the latest response times of 3 hours and 18 minutes on one pendant call recording and 5 hours and 50 minutes on a second pendant call recording. This serves as a potential personal rights risk to residents in care.

Allegations alleges resident services not being provided due to not enough staff is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210712090342

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/22/2024 Section Cited CCR 87411	1 2 3 4 5 6 7	87411 Personnel Requirements General -Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This was not met as evidence by: Based upon review of staff emeregency call button system it was found that	1 2 3 4 5 6 7	Licensee has implemented higher staff counts, hired new Resident Service Director that monitors emergency call systems, multiple nursing staff and additional caregiver staff as of June 2024. Facility also has partnership with outside care agency to address any potential staff shortages.
	8 9 10 11 12 13 14	in July 2021, there were 83 total responses to emergency or pendant calls that were over 30 minutes in response time. In addition, 25 of the emergency or pendant calls were over 1 hour. This serves as a potential health & safety and personal rights risk to residents in care.	8 9 10 11 12 13 14	LPA found that the facility has appropriately addressed the deficiency and will ensure compliance. Deficiency cleared at time of visit.
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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: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

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