435202807-6-6-2025-26-AS-KHOS-DHPMYM-20250616100145

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 06/06/2025
Date Signed: 06/06/2025 11:29:19 AM

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
06/20/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230620154218

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: 80	DATE:	06/06/2025
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Administrator Ida Gemignani-stearns		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Facility staff slapped resident
Facility staff treat resident in a rough manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver complaint investigation findings. LPA met with Administrator Ida Gemignani-stearns, and explained the purpose of the visit.

On June 20, 2023, the Department received a complaint alleging Facility staff slapped resident/ Facility staff treat resident in a rough manner. It has been alleged that staff slapped resident R1 and treated him/her in a rough manner.

On June 28, 2023, LPA Dolores interviewed residents R1-R5. Resident R1 stated he/she could not remember the time of when the incident occurred; however, R1 stated the staff slapped R1's arm, did not know why the staff slapped R1's arm, recalled having two staff assist taking R1 to the bathroom, and remembered the staff were being rough by pushing and poking R1. R1 stated the staff was not patient and telling R1 to hurry up. Page 1 Out of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025

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 3

Control Number 26-AS-20230620154218

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: 06/06/2025

NARRATIVE

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4 Out of 5 residents (R2-R5) interviewed stated they have not seen staff slapping/hitting residents or treating them in a rough manner.

LPA Dolores interviewed staff S1. S1 stated an incident with two staff members (S2, S3) and R1 on 06/16/2023 or 06/17/2023. Based on S1's internal investigation, the staff members denied the allegation of slapping the resident or handling the resident in a rough manner. The staff did admit to assisting the resident with transferring the resident from their wheelchair to the bathroom. S1 stated prior to the incident, there had not been any concerns. S1 did stated R1 could not confirm the cause of the bruise on R1's arm.

LPA Dolores interview witness W1. W1 stated he/she asked R1 about staff slapping R1. R1 was confused and could not answer the question. W1 reported seeing three (3) bruises on R1. W1 stated he/she believed that the bruises may have come from an assistive device that is installed in R1's bathroom. W1 stated R1 has a private caregiver, whom is not associated/employed with the facility, and observed the bruise on R1 on 06/17/2023. W1 stated in terms of R1’s definition of rough, he/she couldn’t get that information from R1.

On May 28, 2025, LPA Monter interviewed residents R6-R13. All residents interviewed stated they have not seen staff slapping/hitting residents or treating them in a rough manner.

LPA Monter interviewed staff S4-S9. All staff interviewed stated they have not seen staff hitting or slapping resident in care. 5 Out of 6 staff interviewed (S4-S7, S9) they have not seen staff handle residents in a rough manner. 1 Out of 6 staff (S8) stated he/she remembers of an event where two staff members were rough when providing care but could not remember where or when this occurred.

On June 4 & 5, LPA Manuel Monter interviewed staff S2 and S3. Both staff interviewed stated they did not hit/slap residents in care. Both staff interviewed stated they did not treat residents in a rough manner. Both staff interviewed stated they haven’t seen staff hit/slap residents in care or staff treating residents in a rough manner.

On June 6, 2025, LPA Monter interviewed staff S10. S10 stated he/she hasn't seen or heard about staff slapping/hitting residents or treating them in a rough manner.
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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20230620154218

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: 06/06/2025

NARRATIVE

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Based on a review of Local Law enforcement report, on June 17, 2023, local law enforcement was informed about the alleged physical abuse of R1. The report indicates staff S2 and S3 as the two staff member in question who were alleged of doing physical abuse.

Based on a review of R1’s Progress notes, dated June 21, 2023, states R1 informed staff that on June 16, 2023 two care givers were rough with him/her. R1 described the staff as Ethiopians, tall slender and could possibly be brothers/sisters. R1 stated when he/she was being transferred, one of the care givers hit him/her on his/her left arm and caused a bruise and a small skin tear.

Based on a review of Accent Care Hospice Provider note, dated June 17, 2023, R1 noted pain to left elbow and skin tear to elbow. R1 stated he/she doesn’t remember exactly what happened but noted small drops of blood on floor to the left of toilet. Appears to have bumped his/her arm on the raised toilet seat handle.

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.

This report was reviewed with ADM Ida Gemignani-stearns and a copy of the report was provided.
Page 3 Out of 3. END OF REPORT.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025

LIC9099 (FAS) - (06/04)

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