435202807-5-7-2025-26-AS-KHOS-DGTKEY-20250519075103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 05/07/2025
Date Signed: 05/07/2025 01:10:32 PM

Substantiated

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:	DATE:	05/07/2025
		UNANNOUNCED	TIME BEGAN:	10:43 AM
MET WITH:	Ida Gemignani-Stearns, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility did not follow physician’s order when administering medication to a resident
Facility increased residents services without proper notice

INVESTIGATION FINDINGS:

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Substantiated

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: 05/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

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 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: 05/07/2025

NARRATIVE

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Complaint alleges facility increased residents services without proper notice. Based upon a review of resident records LPA identified a notice of rate increase dated 11/1/2023. The letter stated that the rate increase for R1 was effective the same date of 11/1/2023 and is not within required time frame to for proper notification. Complaint also indicates an increased level of care not given proper notice. In addition, LPA identified a documented assessment for R1 indicating a higher level of care dated 10/17/2023. However the assessment did not include the increased rate and effective date nor was it signed by R1 or R1's responsible party indicating acknowledgement.

Allegations, facility did not follow physician’s order when administering medication to a resident and facility increased residents services without proper notice are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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:	DATE:	05/07/2025
		UNANNOUNCED	TIME BEGAN:	10:43 AM
MET WITH:	Ida Gemignani-Stearns, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility is charging for services not being provided

INVESTIGATION FINDINGS:

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On 5/7/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Ida Gemignani-Stearns. The department toured the facility, interviewed staff, outside parties, reviewed records and made observations during the course of the investigation.

Complaint alleges facility is charging for services not being provided to resident (R1). Upon review of R1's care plans and medical records, LPA gathered contradicting information regarding R1's assessments for level of care. LPA found R1 had been assessed for a higher level of care after a medical discharge but was reassessed several days after R1 had acclimated back to facility care. In addition, invoice records indicate the facility had credited R1 after reassessment for R1 from a higher to lower level of care. Upon interviews with multiple caregiver staff and a review of R1 records and progress notes, LPA found contradicting information regarding R1's responses to care from staff. R1 is no longer residing in the facility for additional observations.

A finding that the complaint allegation, facility is charging for services not being provided 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.

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: 05/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

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

LIC9099 (FAS) - (06/04)

Page: 3 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/07/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/08/2025 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee to submit a written plan to address administration of medication and to provide staff training such as but not limited documentation of medications records and administration of medication for person in care. Written plan to be submitted by POC date 5/8/2025.
	8 9 10 11 12 13 14		8 9 10 11 12 13 14
Type B 05/14/2025 Section Cited HSC 1569.655(a)	1 2 3 4 5 6 7	1569.655 Increase in fee rates for elderly residents (a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days’ prior written notice...This was not met as evidence by	1 2 3 4 5 6 7	Licensee to submit written plan to ensure compliance with proper notification of rate increases for all persons in care. Written plan to be submitted by POC date 5/14/2025.
	8 9 10 11 12 13 14		8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC9099 (FAS) - (06/04)

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