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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202807
Report Date: 12/04/2024
Date Signed: 12/04/2024 03:44:53 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/04/2024 03:44 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 GLENFACILITY NUMBER:
435202807
ADMINISTRATOR/
DIRECTOR:		GOLDEN, KIMFACILITY TYPE:
740
ADDRESS:1420 CURCI DRIVETELEPHONE:
(408) 283-0941
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY: 150TOTAL ENROLLED CHILDREN: 0CENSUS: 88DATE:
12/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Karen NickolaiTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Annual Continuation visit and met with Karen Nickolai, Administrator. The visit was a continuation of the Required 1 Year Annual Inspection that was started on 11/27/2024.

During visit on 11/27/2024, LPA Marrufo reviewed the resident medication records for residents R1-R8. The Centrally Stored Medication and Destruction Records for R3, R4, R5, R6, and R8 had prescription numbers that were incorrect.

LPA reviewed the resident records for R1-R8 and staff records for 8 staff and found them to be complete.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information.

This report was reviewed with Administrator Karen Nickolai and a copy of this report and appeal rights were provided.
Sarah YipTELEPHONE: (408) 324-2131
David MarrufoTELEPHONE: (650) 380-0519
DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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Document Has Been Signed on 12/04/2024 03:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 435202807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87465(h)(6)(E) Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored
Deficient Practice Statement
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POC Due Date: 12/11/2024
Plan of Correction
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Licensee agrees to conduct in-service training with staff to ensure that staff correctly record the prescription numbers of resident medications in the Centrally Stored Medication Logs by POC Due Date. The Licensee agrees to submit copies of staff training records that include names of
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Sarah YipTELEPHONE: (408) 324-2131
David MarrufoTELEPHONE: (650) 380-0519

DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024

LIC809 (FAS) - (06/04)
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