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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 07/14/2025
Date Signed: 07/14/2025 03:32:32 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
02/13/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240213143445
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: 82DATE:
07/14/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Ida Gemignani-stearns TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident is not being assisted with ADLs
Facility is not providing the services to meet residents needs due to lack of staffing numbers
Facility has a foul urine odor
Facility staff is not reporting medication errors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Ida Gemignani-stearns.

On February 13, 2024 , the Department received a complaint alleging Resident is not being assisted with ADLs/ Facility is not providing the services to meet residents needs due to lack of staffing numbers/ Facility has a foul urine odor

On February 16, 2024, LPA Simi Rai conducted the initial complaint investigation visit.

LPA Rai interviewed residents R1-R3. R1-R3 stated they don’t know if they are being assisted with ADL’s. R1-R3 stated when they need help, staff help them. R1 and R3 stated they haven’t smelled a foul urine odor in his/her room. R2 stated he/she doesn’t know if there is a foul odor in his/her room. Page 1 Out of 4
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
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 8
Control Number 26-AS-20240213143445
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: 07/14/2025
NARRATIVE
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LPA Rai interviewed staff Former Administrator Will Carter, referred to as S1. S1 stated their Staffing model, allows number of staff based upon care administering each care has a point value, and there is a minute value associated with the point value. S1 stated Every week the housekeeping is being provided to the residents.

On May 28, 2025, LPA Manuel Monter interviewed residents R4-R11. R4-R11 stated their rooms are clean. R4-R11 stated they haven’t seen any other residents bedrooms as dirty or with foul odors. R4-R8, R10-R11 stated there is enough staff to meet the needs of the residents. R9 stated there is not enough staff to meet the needs of the residents and that there are days when the staff is short staffed.

R4-R5, R10-R11 stated there hasn’t been a time when they haven’t been assisted with their ADL’s. Residents R6 - R9 stated they don’t need assistance with their ADL’s from the facility staff.

LPA Monter interviewed ADM. ADM stated the facility staff provides residents assistance with their ADL’s. ADM stated there hasn’t been an instance where a resident was neglected or didn’t receive ADL assistance. ADM stated there is enough staff to meet the needs of the residents. ADM stated the staffing is based on the care levels of residents. ADM stated she hasn’t seen any residents bedroom in disrepair or with foul odors.

On May 28 and June 16, 2025, LPA Monter interviewed staff S2-S8. Staff S2 -S7 stated there hasn’t been a time when resident haven’t been assisted with their ADL’s. Staff S8 stated there has been some delays. S8 stated some residents want their shower earlier. S8 stated the issue is regarding the expectations. S8 stated the facility does their best to meet them when they want.

Staff S2-S7 stated she hasn’t seen any bedrooms in disrepair or with foul odors. Staff S8 stated resident bedroom as are cleaned, and if a resident asks their room to be cleaned, then staff will clean their room.

Staff S2 -S7 stated there is not enough staff to meet the needs of residents. S8 stated staffing is based on the residents acuity/ Care Levels & the facility does have enough staff.

Page 2 Out of 4.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 26-AS-20240213143445
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: 07/14/2025
NARRATIVE
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On May 28, 2025, LPA Monter toured the following bedrooms. Garden house bedrooms 1-13 & Assisted living bedrooms, 111, 132, 229, 219, 303, 316, 412,427. LPA observed these bedrooms as clean, and in good repair.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Facility staff is not reporting medication errors

On February 13, 2024, the Department received a complaint alleging Facility staff is not reporting medication errors.

On February 16, 2024, LPA Simi Rai conducted the initial complaint investigation visit.

LPA Rai interviewed staff Former Administrator Will Carter, referred to as S1. S1 stated there have been issues in the past were staff did not report in a timely manner. S1 stated He filled out an incident report, Same day, same shift to say that the error had occurred.

On May 28 and June 16, 2025, LPA Monter interviewed staff S2-S8. Staff S2 & S6 stated there has been medication errors in the past but doesn’t know if it was reported.

Staff S3 - S5 & S7 stated facility staff is reporting medication errors. Staff S8 stated the facility policy regarding medication error is to report it to licensing, their regional nurse and discuss actions on how to prevent this from occurring. S8 stated they had heard allegations of errors not being reported. S8 stated he believes this is interpersonal conflicts between Medtech’s.

LPA Monter interview ADM. ADM stated regarding medication errors, they report it to resident care director who will catch it. ADM stated they Follow reporting requirements and list why it was missed. ADM stated she hasn’t been informed about any medication errors while she has been the administrator. Page 3 Out of 4.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 26-AS-20240213143445
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: 07/14/2025
NARRATIVE
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On July 14, 2025, LPA Monter randomly audited 4 resident medication records. The medication audit was completed by cross-referencing the residents’ medications containers with the Centrally Stored Medication log and the Medication Administration Record. As a result, LPA did not find any discrepancies on medications.

Based on records reviewed, the facility has reported medication errors for the year. The facility submitted 2 incident reports for medication errors in 2024.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Page 4 Out of 4.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8
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
02/13/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240213143445

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: 82DATE:
07/14/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Ida Gemignani-stearns TIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility staff are providing care to residents under the influence
Facility staff makes fun of residents physical appearance





INVESTIGATION FINDINGS:
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On February 13, 2024, the Department received a complaint alleging Facility staff are providing care to residents under the influence / Facility staff makes fun of residents physical appearance.(This Report is being amended, to change the findings for the allegation,Facility has cockroaches in resident room, from Unfounded to Substantiated, due to erroneous finding on previous report.)

On February 16, 2024, LPA Simi Rai conducted the initial complaint investigation visit.

LPA Rai interviewed residents R1-R3. All residents interviewed stated they don’t know if staff are under the influence. All residents interviewed stated they don’t know if staff make fun of the residents.
LPA Rai interviewed staff Former Administrator Will Carter, referred to as S1. S1 stated he is not aware of staff smoking e-cigarette's. S1 stated There is supervision over the staff including MedTech to ensure there is no activity of being under the influence. S1 stated he is not aware of facility staff making fun of residents physical appearance. Page 1 Out of 4.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 26-AS-20240213143445
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: 07/14/2025
NARRATIVE
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On May 28, 2025, LPA Manuel Monter interviewed residents R4-R11. All residents interviewed stated they have not observed staff working under the influence. All residents interviewed stated they have not heard staff making fun of residents.

LPA Monter interviewed ADM. ADM stated he/she has never seen staff smoking/consuming drugs/ Alcohol. ADM stated he/she has never seen staff smoking marijuana in the facility. ADM stated he/she has never seen staff working while intoxicated. ADM stated he/she has not seen or heard staff making fun or ridiculing residents for their physical appearance.

On May 28 and June 16, 2025, LPA Monter interviewed staff S2-S8. All staff interviewed stated they have not observed staff working under the influence. All staff interviewed stated they have not heard staff making fun of residents.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

(This Report is being amended, to change the findings for the allegation, Facility has cockroaches in resident room, from Unfounded to Substantiated, due to erroneous finding on previous report.)

Page 2 Out of 4.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 26-AS-20240213143445
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: 07/14/2025
NARRATIVE
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(This Report is being amended, to change the findings for the allegation, Facility has cockroaches in resident room, from Unfounded to Substantiated, due to erroneous finding on previous report.)

Page 3 Out of 4.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 26-AS-20240213143445
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: 07/14/2025
NARRATIVE
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(This Report is being amended, to change the findings for the allegation, Facility has cockroaches in resident room, from Unfounded to Substantiated, due to erroneous finding on previous report.)

Page 4 Out of 4.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8