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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202807
Report Date: 10/20/2021
Date Signed: 10/21/2021 08:28:20 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:
435202807
ADMINISTRATOR:KOMASAKA, GRACEFACILITY TYPE:
740
ADDRESS:1420 CURCI DRIVETELEPHONE:
(408) 283-0941
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:150CENSUS: 84DATE:
10/20/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Corinne GiesTIME COMPLETED:
04:30 PM
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At approximately 11:10 AM, Licensing Program Analysts (LPA) Steve Nguyen, conducted a Pre-Licensing Inspection at facility. LPA met with Administrator (AD), Corinne Gies; explained the purpose of the visit, and conducted an inspection of facility inside and out.

Facility’s exits were observed to be free of hazards and obstructions. The facility has an Emergency Disaster Preparedness Plan in place, including Covid 19 preparedness. Smoke and carbon monoxide detectors are connected. All toxins, cleaning supplies and hazardous materials were locked . Water temperature in bathroom was checked and it was at 110 degrees. Fire extinguishers located on all four floors of building; extinguishers were checked on 12/21/2020. Observed that facility has 7 days of perishable and 7 days Non-perishable foods on site.

Medications secured in Medroom. First Aid kit was stocked with supplies to include but not limited to: scissors, thermometer, and first aid manual.

Resident and personnel files observed to contain all necessary documentation, including but not limited to: Appraisal Needs and Services Plans, Physician's Reports, first aid certifications, Dementia training certifications, and criminal background clearances.

At approximately 3:50 PM, review of Component III was completed.

The physical plant is approved for Licensure pending the final approval by Centralized Application Bureau (CAB). No deficiencies were cited per the California Code of Regulation Title 22.

LPA review report summary with AD, Corinne Gies, and a copy was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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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