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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 12:20:42 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
01/19/2022 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 26-AS-20220119100726
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:
11:15 AM
MET WITH:General Manager, Karen NickolaiTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
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9
Facility doesn't have proper emergency protocols for wheelchair bound resident's
INVESTIGATION FINDINGS:
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2
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5
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9
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13
On 11/15/2024, Licensing Program Analysts (LPA's) Tobola & 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 facility doesn't have proper emergency protocols for wheelchair bound resident's. Based upon tour of the facility and interviews with Executive Director, LPA found that the facility protocol for assisting non-ambulatory residents out of the facility included the use of emergency evacuation chairs. Upon inspection LPA's observed multiple evacuation chairs located at each stairwell on the second and fourth floors. LPA's did not observe any of the facility stairwells without an evacuation chair present at the time of visit.

A finding that the complaint allegations, facility doesn't have proper emergency protocols for wheelchair bound resident's 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)
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