435202807-3-13-2025-26-AS-KHOS-DGTKEZ-20250519075104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 03/13/2025
Date Signed: 03/13/2025 03:04:13 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
10/31/2023 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 26-AS-20231031135900

FACILITY NAME:	MERRILL GARDENS AT WILLOW GLEN		FACILITY NUMBER:	435202807
ADMINISTRATOR:	GOLDEN, KIM		FACILITY TYPE:	740
ADDRESS:	1420 CURCI DRIVE		TELEPHONE:	(408) 283-0941
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95126
CAPACITY:	150	CENSUS: 87	DATE:	03/13/2025
		UNANNOUNCED	TIME BEGAN:	11:01 AM
MET WITH:	Will Carter, General Manager		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility is not accommodating to the residents preference by not providing an alternative to water
Facility did not provide proper supervision in the dining room of memory care
Facility is not changing resident's diaper

INVESTIGATION FINDINGS:

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On 3/13/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by General Manager, Will Carter The department toured the facility, interviewed staff, outside parties, reviewed records and made observations during the course of the investigation.

Complaint alleges facility is not accommodating to the residents preference by not providing an alternative to water. Upon interviews with multiple caregiver staff, LPA was informed that other beverage options are available and offered to residents and resident (R1) including juice, coffee, tea, ensure and other flavored beverage packets. Upon tour of the memory care unit, LPA confirmed several beverage options available for residents including but also alternative to water. R1 is no longer residing in the facility for additional observations.

Continued onto LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

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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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
10/31/2023 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 26-AS-20231031135900

FACILITY NAME:	MERRILL GARDENS AT WILLOW GLEN		FACILITY NUMBER:	435202807
ADMINISTRATOR:	GOLDEN, KIM		FACILITY TYPE:	740
ADDRESS:	1420 CURCI DRIVE		TELEPHONE:	(408) 283-0941
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95126
CAPACITY:	150	CENSUS: 87	DATE:	03/13/2025
		UNANNOUNCED	TIME BEGAN:	11:01 AM
MET WITH:	Will Carter, General Manager		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility is not updating residents physician’s reports in memory care

INVESTIGATION FINDINGS:

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On 3/13/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by General Manager, Will Carter The department toured the facility, interviewed staff, outside parties, reviewed records and made observations during the course of the investigation.

Complaint alleges facility is not updating residents physician’s reports in memory care. Based upon review of resident R1 records, LPA identified a physician's assessment to be completed as of April 2023 and within regulation from time of the reported allegation.

The agency has investigated the allegation and we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies cited.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20231031135900

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: 03/13/2025

NARRATIVE

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Complaint alleges facility did not provide proper supervision in the dining room of memory care. Upon review of R1 progress notes and interviews with multiple caregiver staff, LPA was informed that R1 had a history of verbal and physical behaviors towards staff and other residents in care. Upon tour of the memory care unit, LPA observed one common area connected to a dinning space, which complete separation of residents poses a difficulty. Staff indicated proper responses for redirection and ensuring resident personal rights, all while attempting to address R1's behaviors. LPA did not find any indications or observations of staff not providing appropriate supervision to residents in the dinning area.

Complaint alleges facility is not changing resident's diaper. Upon interview with multiple caregiver staff and a review of R1 records and progress notes, LPA found contradicting information regarding R1's responses to continence care from staff. Staff statements were consistent to frequency of resident checks and attempts and did not provide corroborating evidence. R1 is no longer residing in the facility for additional observations. Upon tour of the memory care unit, LPA did not observe any other residents that weren't provided adequate continence care.

A finding that the complaint allegations, facility is charging for services not being provided, facility is not accommodating to the residents preference by not providing an alternative to water, facility did not provide proper supervision in the dining room of memory care, facility is not changing resident's diaper are 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 Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC9099 (FAS) - (06/04)

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