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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 11/15/2024
Date Signed: 11/15/2024 12:18:02 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
01/18/2022 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 26-AS-20220118151741
FACILITY NAME:MERRILL GARDENS AT WILLOW GLENFACILITY NUMBER:
435202807
ADMINISTRATOR:GOLDEN, KIMFACILITY TYPE:
740
ADDRESS:1420 CURCI DRIVETELEPHONE:
(408) 283-0941
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:150CENSUS: 90DATE:
11/15/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:General Manager, Karen NickolaiTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident's call cord is in disrepair
INVESTIGATION FINDINGS:
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On 11/15/2024, Licensing Program Analysts (LPA's) 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 staff and made observations during the course of the investigation.

Complaint alleges, resident’s call cord is in disrepair. Based upon a tour of the facility, LPA tested call bell/chords in multiple resident bedrooms on each floor throughout the facility. Upon LPA observation, staff were notified and responded appropriately with no indication of call cords damaged. Due to a lack of corroborating evidence, the allegation is found to be unsubstantiated.

A finding that the complaint allegations, resident's call cord is in disrepair is unsubstantiated meaning 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, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited during today's visit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (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)
Page: 1 of 2
Control Number 26-AS-20220118151741
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: 435202807
VISIT DATE: 11/15/2024
NARRATIVE
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A finding that the complaint allegations, resident's call cord is in disrepair is unsubstantiated meaning 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, therefore the allegations are UNSUBSTANTIATED.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (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)
Page: 2 of 2