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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202725
Report Date: 04/24/2025
Date Signed: 04/24/2025 01:28:28 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
02/21/2025 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20250221111446
FACILITY NAME:WILLOW GLEN SENIOR LIVINGFACILITY NUMBER:
435202725
ADMINISTRATOR:MERLA BANGLAYANFACILITY TYPE:
740
ADDRESS:2991 FAIRCLIFF CTTELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 6DATE:
04/24/2025
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:ADM Merla BanglayanTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Facility is not meeting needs of residents with bladder/bowl incontinence at night
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with ADM Banglayan

On February 21, 2025, the Department received a complaint alleging Facility is not meeting needs of residents with bladder/bowl incontinence at night. It has been alleged that the facility could not meet resident R1’s bladder/bowl incontinence needs at night.

On February 27 and April 22, 2025, LPA interviewed Witness W1. W1 stated the Licensee complained to him/her that she had to pay for overtime, to meet R1’s needs at night. W1 acknowledged that he/she doesn’t know if the facility were or were not meeting R1’s incontinence needs at night. W1 stated it might have been happening, but he/she doesn't know for a fact.

Page 1 Out of 3
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 12
Control Number 26-AS-20250221111446
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: WILLOW GLEN SENIOR LIVING
FACILITY NUMBER: 435202725
VISIT DATE: 04/24/2025
NARRATIVE
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On February 28, 2025, Licensing Program Analyst Monter interviewed residents R2-R7. R2 and R6 stated his/her bathroom needs are being meet at night. R3-R5 stated they doesn’t need assistance to use the restroom. Residents R2-R6 stated they have a call pendant they can press at night, and a care giver will assist them at night. Resident R7 stated he/she declined to be interviewed.

LPA interviewed staff S1 and S2. S1 stated all the residents have a pendant. S1 and S2 stated if the residents need help, they press the pendant, and staff will go help them. S1 and S2 stated assistance is always provided when residents press the pendant.

LPA interviewed Licensee Ladwig. LN stated R1 has the condition of going to the bathroom at night. LN stated R1 had an issue of having the sensation of needing to go to the bathroom. LN stated the staff was able to meet R1 needs incontinence needs at night.

On April 9 and 21, 2025, LPA Monter interviewed staff S3-S5. Staff S3 stated he/she works the night shift. S4 stated he/she will cover the night shift for S3 when he/she calls in sick. S3 and S4 stated residents are checked/ changed every 2 hours at night. S3 and S4 stated staff respond to pendants, when pressed during the day and night. S3 and S4 stated they didn’t work with R1.

Staff S5 stated he/she did work with R1 during the night shift. S5 stated resident R1 will get up multiple times at night, at least 4 times a night. S5 stated R1 will go to the bathroom by him/herself. S5 stated resident R1 has unsteady balance and for R1’s safety staff needs to be there to assist R1 in walking. S5 stated R1 will get out of his/her bed and use his/her walker to go to the bathroom, which is only 5 feet away from the bathroom.

S5 stated he/she will hear a noise and will hear R1’s walker and S5 will go to assist R1.
S5 stated R1 will sometimes use the pendant, call button to get assistance, but R1 most of the time would rather go by him/herself to the bathroom.

Page 2 Out of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 12
Control Number 26-AS-20250221111446
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: WILLOW GLEN SENIOR LIVING
FACILITY NUMBER: 435202725
VISIT DATE: 04/24/2025
NARRATIVE
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LPA interviewed Facility ADM. ADM stated at nighttime R1 would go to the bathroom by him/herself. ADM stated R1 would get up 1-4x a night and has the sensation of wanting to pee. ADM stated R1’s bedroom was directly across from the restroom, two steps away. ADM stated R1 can get up and walk with his/her cane to the bathroom. ADM stated the night staff know to assist R1 at night and do assist R1 when he/she wants to use the restroom.

On April 23, 2025, LPA Monter interviewed Witness W1 and W2. Both witnesses interviewed stated R1 can stand up by him/herself and walk, with a walker, to the restroom across his/her bedroom to use the restroom, with supervision for his/her safety. W1 stated based on his/her observations, he/she didn’t witness him/herself any signs that R1’s incontinence needs were not being met. W2 stated there have been instances where he/she has found R1 sitting in soiled sheets that have already been dried but does not recall the dates when this occurred. W2 stated he/she has also found the resident soaked but stated he/she doesn’t know if it had been left soaked for an extended period and does not recall.

Based on a review of R1’s Physician’s Report, dated July 15, 2024, R1 is able to independently transfer to and from bed. R1 also has bladder impairment.

The Department reviewed R1’s Appraisal/Needs and Services Plan (ANS), dated October 29, 2024. The ANS states R1 is ambulatory with steady gait, able to move around independently, required supervision and assistance as needed in activity of daily living. R1 will be provided assistance as needed for toileting. Facility staff will check if wet and assist when changing diaper.

The Department was unable to interview Resident R1, who no longer lives at the facility.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Page 3 Out of 3. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 12
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
02/21/2025 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20250221111446

FACILITY NAME:WILLOW GLEN SENIOR LIVINGFACILITY NUMBER:
435202725
ADMINISTRATOR:MERLA BANGLAYANFACILITY TYPE:
740
ADDRESS:2991 FAIRCLIFF CTTELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 6DATE:
04/24/2025
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:ADM BanglayanTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Staff did not ensure facility is free from pests
Facility is not following food storage procedures, which endangers food safety, acceptability and nutritive values.
INVESTIGATION FINDINGS:
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On February 21, 2025, the Department received a complaint alleging staff did not ensure facility is free from pests. It has been alleged that the facility has cockroaches.

On February 28, 2025, Licensing Program Analyst Monter interviewed residents R2-R7. R2 stated that he/she has observed bugs inside the facility but stated he/she doesn’t know and couldn’t describe bugs to LPA.

R3 stated he/she has observed cockroaches in the bathroom, kitchen as recently as February 26, 2025. Resident R4 stated he/she hasn’t seen pests or cockroaches inside the facility. R5 stated he/she has seen cockroaches in the kitchen, the living room wall, and the bathroom, recently, but doesn’t remember the exact date.

Page 1 Out of 4
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 12
Control Number 26-AS-20250221111446
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: WILLOW GLEN SENIOR LIVING
FACILITY NUMBER: 435202725
VISIT DATE: 04/24/2025
NARRATIVE
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R6 stated a couple months ago, he/she saw a cockroach in the bathroom. R6 stated he/she hasn’t seen the cockroaches or pests recently. Resident R7 stated he/she declined to be interviewed.

On February 28, 2025, LPA Monter interviewed Licensee Ladwig (LN). LN stated ever since November 2024, the facility has been aware of the cockroaches and has been spraying. LN stated it’s an ongoing issue, and the facility has traps, cleaning and people who come and spray.

On February 28, April 9 & 22, 2025, LPA Monter interviewed Staff S1-S5. S1 stated he/she hasn’t seen cockroaches inside the facility. S2 stated he/she has seen cockroaches in the facility kitchen. S2 stated he/she hasn’t seen cockroaches lately. S2 stated the first time he/she saw the cockroaches was in January 2025. S2 stated the last time he/she saw a cockroach was in the middle of February 2025. S3 he/she has not seen cockroaches or pests in the facility. S4 stated he/she has not seen cockroaches or pests in the facility. S5 stated he/she has seen cockroaches all over the facility. S5 stated the last time he/she saw cockroaches in the facility was in December 2024.

On April 9, 2025, LPA Monter interviewed facility ADM. ADM stated she has seen cockroaches, in kitchen and both restrooms. ADM stated the facility is currently spraying to address the pest issue. ADM stated the pest control company just came yesterday.

On April 23, 2025, LPA Monter interviewed Witness W1 and W2. Both witnesses interviewed stated they have seen cockroaches in R1’s bedroom and kitchen. Both witnesses interviewed stated the last time they saw cockroaches in the facility was in November 2024.

Based on a review of the facility’s Pest Control Log, the log states the facility took actions to address cockroaches, on April 3, 2024. The Pest Control Log notes, the facility took actions to address cockroaches in May 2024, July 2024, August 2024, October 2024, November 2024, December 2024, February 2025, and March 2025.

Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.
Page 2 Out of 4
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 12
Control Number 26-AS-20250221111446
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: WILLOW GLEN SENIOR LIVING
FACILITY NUMBER: 435202725
VISIT DATE: 04/24/2025
NARRATIVE
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Facility is not following food storage procedures, which endangers food safety, acceptability and nutritive values.

On February 21, 2025, the Department received a complaint alleging facility is not following food storage procedures, which endangers food safety, acceptability and nutritive values.

On February 28, 2025, Licensing Program Analyst Monter arrived unannounced to open the initial complaint investigation. During visit, LPA toured the facility inside and out.

While touring the kitchen, LPA exited toward the backyard. LPA observed a stack of 5 cardboard boxes. LPA observed an assortment of cucumbers, apples, potatoes, eggplants in the first 3 boxes.

Directly below these 3 boxes, was an additional two cardboard boxes. These boxes were designed with openings on the side to pick up. On the top of these two cardboard boxes was a gap reveling the contents of the box. Inside the bottom 2 boxes, LPA observed several broccoli and pieces of carrot. LPA observed the head of the broccoli had yellow and brown spots.

LPA Monter interviewed Staff S1 and S2. S1 stated the broccoli food box is outside, near the sliding screen door, because the trash can is already full, and the broccoli was moldy. LPA asked S1 why the box of squash, eggplant and apples was placed on top of the spoiled broccoli. S1 stated they put the box of food there because there wasn’t any room inside the kitchen. S2 stated they put the broccoli outside, next to the sliding screen door because there is not enough room in the trash can. LPA asked why the box of vegetables is on top of the broccoli. S2 stated the facility kitchen is full and they have no space. S2 stated they put the box of food there while they make more room in the kitchen.

Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Page 3 Out of 4.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 12
Control Number 26-AS-20250221111446
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: WILLOW GLEN SENIOR LIVING
FACILITY NUMBER: 435202725
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by;
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ADM stated they will submit a written plan of action on how they will ensure the facility is free from cockroaches. Licensee/ADM will seek professional help if the issue cannot be addressed.
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Based on observation, record review and interview the licensee did not ensure the facility was free of cockroaches. This poses an immediate health, safety and personal rights risk to residents in care.
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ADM stated they will submit the written plan of action to the Department by POC due date April 25,2025.
Type A
04/25/2025
Section Cited
CCR
87555(b)(28)
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87555 General Food Service Requirements (b)(28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement was not met as evidence by:
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ADM stated to submit a Plan of Correction on how she will ensure all Contaminated food shall be discarded immediately upon discovery.
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Based on interview and observation, staff stored vegetables, fruits on top of a cardboard box of molding broccoli. This poses an immediate health, safety and personal rights risk to residents in care.
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ADM stated she will submit the plan of correction to LPA by POC date, 4/25/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 12
Control Number 26-AS-20250221111446
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: WILLOW GLEN SENIOR LIVING
FACILITY NUMBER: 435202725
VISIT DATE: 04/24/2025
NARRATIVE
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A civil penalty of $250 is being cited for a repeat violation, for the following code section: 87303 Maintenance and Operation (a), which was cited during a complaint investigation visit on August 14, 2024.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with ADM Banglayan and a copy of the report was provided. Appeal Rights was provided. Page 4 Out of 4. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 12
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
02/21/2025 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20250221111446

FACILITY NAME:WILLOW GLEN SENIOR LIVINGFACILITY NUMBER:
435202725
ADMINISTRATOR:MERLA BANGLAYANFACILITY TYPE:
740
ADDRESS:2991 FAIRCLIFF CTTELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 6DATE:
04/24/2025
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:ADM BanglayanTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Facility is not administering residents medications, as prescribed by physician
Staff are unable to communicate with residents due to language barrier.
Staff do not ensure facility is free from tripping hazards.
INVESTIGATION FINDINGS:
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On February 21, 2025, the Department received a complaint alleging Facility is not administering residents’ medications, as prescribed by physician.

On February 28, 2025, Licensing Program Analyst Monter interviewed residents R2-R7. 5 Out of 6 residents interviewed (R2-R6) stated they have not had any issues with medication administration or been a day when staff have not given their medication. Resident R7 stated he/she declined to be interviewed.

LPA Monter interviewed staff S1 & S2. Both staff interviewed stated residents get their medications every day. Both staff interviewed stated there hasn’t been a day when a resident has missed their medication.

Page 1 Out of 4.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 9 of 12
Control Number 26-AS-20250221111446
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: WILLOW GLEN SENIOR LIVING
FACILITY NUMBER: 435202725
VISIT DATE: 04/24/2025
NARRATIVE
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On February 28, 2025 LPA Monter interviewed Licensee Ladwig (LN). LN stated the facility has been administering resident’s medications and there hasn’t been any issue with medications and residents haven’t missed their medications.

On April 9 and 22, 2025, LPA interviewed staff S3, S4, S5 and Administrator Merla Banglayan. Staff S3-S5 stated residents get their medications every day and there hasn’t been a day when a resident has missed their medication. ADM stated residents get their medications every day. ADM stated there hasn’t been a time when residents medications were missed or not administered.

On April 9, 2025, LPA Manuel Monter randomly audited 3 resident’s medications. LPA audited the medications by cross referencing the medication bottles/ containers and cross referencing with the Centrally Stored Medication Record and Medication Administration Record. No discrepancies were noted during review.

On April 23, 2025, LPA Monter interviewed Witness W1 and W2. W1 stated there has been an instance when medication had been prescribed but was not administered to R1. W1 stated he/she observed the medication administration was not marked on the Medication Administration Log. W1 stated he/she did not do an actual medication audit at the time and does not know for sure if the medication was or was not administered. W1 stated he/she does not remember the name of the medication with the noted discrepancy. W2 stated he/she did not observe any issues with regarding residents medications.

Based on a review of R1’s Centrally Stored Medication Record, Medication Administration Record & PRN log, there was no discrepancy in R1’s medication records.

The Department was unable to interview Resident R1, who no longer lives at the facility.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Page 2 Out of 4
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 10 of 12
Control Number 26-AS-20250221111446
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: WILLOW GLEN SENIOR LIVING
FACILITY NUMBER: 435202725
VISIT DATE: 04/24/2025
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Staff do not ensure facility is free from tripping hazards.
On February 21, 2025, the Department received a complaint alleging Staff do not ensure facility is free from tripping hazards.

On February 28, 2025, Licensing Program Analyst Monter arrived unannounced to open the initial complaint investigation. During visit, LPA toured the facility inside and out.
While touring the facility LPA did not observe any tripping hazards.

LPA Monter interviewed Licensee Ladwig. LN stated the home does not have any tripping hazards. LN stated she and her staff know to remove any tripping hazards or obstructions in the home.

On April 9, 2025, LPA Monter arrived unannounced to conduct a follow up visit to continue the complaint investigation. During visit, LPA toured the facility inside and out.
While touring the facility LPA did not observe any tripping hazards.

LPA interviewed Facility Administrator. ADM stated the home does not have any tripping hazards. ADM stated she and staff ensure there isn’t any tripping hazards in the home. ADM stated she always removes anything potential tripping hazards.

On April 23, 2025, LPA Monter interviewed Witness W1 and W2. Both witnesses interviewed stated they have not seen tripping hazards in the facility.

On April 24, 2025, LPA Monter arrived unannounced to conduct a follow up visit to continue the complaint investigation. During visit, LPA toured the facility inside and out. While touring the facility LPA did not observe any tripping hazards.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 11 of 12
Control Number 26-AS-20250221111446
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: WILLOW GLEN SENIOR LIVING
FACILITY NUMBER: 435202725
VISIT DATE: 04/24/2025
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Staff are unable to communicate with residents due to language barrier.

On February 21, 2025, the Department received a complaint alleging Staff are unable to communicate with residents due to language barrier.

On February 28, 2025, Licensing Program Analyst Monter interviewed residents R2-R7. R2-R6 stated they are able to communicate with staff, and staff are able to respond to their requests. Resident R7 stated he/she declined to be interviewed.

On February 28, April 9 & 21, 2025, LPA interviewed Staff S1-S5. All staff interviewed were able to answer LPA’s questions regarding the other allegations. All staff interviewed were able to answer that staff are supposed to do in an emergency situation such as a fire.

LPA interviewed ADM and Licensee. ADM and LN stated all facility staff are able to communicate in English with residents in care.

On April 23, 2025, LPA Monter interviewed Witness W1 and W2. Both witnesses interviewed stated staff are able to communicate when speaking to facility staff.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Page 4 Out of 4. END OF REPORT
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 12 of 12