435202807-6-27-2025-26-AS-KHOS-DJDMKS-20250708094113

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 06/27/2025
Date Signed: 06/27/2025 10:20:32 AM

Unfounded

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
09/19/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230919081904

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: 79	DATE:	06/27/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Resident Care Director Michael Lucio		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility staff did not report a resident's fall to responsible parties
Facility did not ensure resident's safety, result in resident sustaining an injury.
Facility is charging resident for unauthorized services
Facility staff administered medication without physician's order.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver complaint investigation findings. LPA met with Resident Care Director Michael Lucio, and explained the purpose of the visit.

On September 19, 2023, the Department received a complaint alleging, Facility did not ensure resident's safety, result in resident sustaining an injury. // Facility staff did not report a resident's fall to responsible parties. It has been alleged that resident R1’s Family member (FM1) was not notified about R1’s fall on September 13, 2023.

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Unfounded

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: 06/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025

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 5

Control Number 26-AS-20230919081904

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: 06/27/2025

NARRATIVE

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On September 27, 2023, LPA Simi Rai interviewed Staff 1 (S1). S1 stated Resident 1 (R1) sustained a bruise and a small laceration on R1's right eye after attempting to reach something on the counter and slipped and fell. During the incident, R1's private companion was in the room and notified staff. Staff contacted 911. R1 was not transported to the emergency room and signed a release form due to the fire department saying there was no ambulances available and an eight hour wait for the emergency room. According to S1, R1 did not have a responsible party.

LPA Simi Rai interviewed staff S2. S2 stated the facility checks on R1, if the private companion does not come to the facility, every two hours. S2 stated R1 has a pendent to call staff but does not use it. S2 reports that R1's service only include medication assistance. According to an interview with Staff 2 (S2), R1 fell on September 13, 2023 at 6:00 PM. R1 reported the fall at 6:05 PM. R1's care companion called the receptionist. Staff observed R1 on the floor in the kitchen with a bump on the forehead and a "gash" on the left hand. R1 told the fire department R1 would like to stay at the facility. Staff provided ice compress for the swelling on the hand and head. The facility notified R1's PCP via fax. Since R1 did not have a responsible party at the time of the fall, there was no report made.
On September 27, 2023, during an interview with R1, R1 did not want to discuss R1's injury. When asked if R1 had a fall recently, R1 did not know. R1 reported feeling satisfied with the services provided by facility staff and says R1 is receiving care from the staff. When asked about the bandage on R1's hand, R1 did not wanted to discuss the injury and could not recall the incident.

Based on a review of R1’s Progress notes, dated September 13, 2023, R1’s companion called the receptionist and stated R1 had fallen. When staff arrived, the resident was found sitting on the floor in the kitchen. R1 had a skin tear on his/her left hand, a gash on his/her right side of his/her face near his/her eyebrow and a bump on his/her forehead. 911 was contacted to assess R1. R1 decided to just stay home.

Based on a review of R1’s file, R1 had a durable power of attorney, which was executed on October 10, 2023. FM1 is not listed as the durable power of attorney.

Based on a review of R1’s admission agreement dated February 28, 2023, R1 does not have any noted responsible party. Page 2 Out of 5.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20230919081904

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: 06/27/2025

NARRATIVE

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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.

Facility staff administered medication without physician's order.

On September 19, 2023, the Department received a complaint alleging Facility staff administered medication without physician's order

On September 19, 2023, the Department interviewed Witness W1. W1 stated the facility was providing R1 with a medication M1 that had yet to be released to the facility. W1 stated the order for the new medication was never provided and was confused on how R1 would be taking the medication without the physician order. W1 stated that she is confused about the matter and that she can't elaborate further regarding the matter. It has been alleged that medication M1 was administered without the physician’s order.

On September 27, 2023, LPA Simi Rai interviewed staff S2. S2 stated R1's PCP ordered a new medication on 09/01/2023. Prior to R1's dementia diagnosis, R1 was responsible for own medications, ordering the medication, and administering them. After the diagnosis, R1's services changed from independent to assisted living.

According to an interview with R1, R1 reported waiting on one of the medications already being ordered and waiting for it to deliver to the facility.

Based on a review of Kaiser Permanente fax communication, dated September 1, 2023, R1 was prescribed medication M1.

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.

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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: 06/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20230919081904

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: 06/27/2025

NARRATIVE

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Facility is charging resident for unauthorized services

On September 19, 2023, the Department received a complaint alleging Facility is charging resident for unauthorized services. It has been alleged the facility did not consult with Resident Barbara's Family Member, referred to as FM1 and obtain permission to hire a private caregiver for the resident prior to employing the private caregiver.

On September 27, 2023, LPA Simi Rai interviewed Staff 1. S1 stated R1 agreed to paying for a private companion on September 4, 2023 after the facility observed R1 was having eloping behavior. The eloping incident occurred during a NOC shift. NOC shift staff observed R1 entering the facility at 5:00AM and was unaware that R1 left the facility. S1 stated the private companion is with the resident every day from 7:00 AM - 7:00 PM.

S2 stated R1 had private companion services because of R1’s change of condition and to established for his/her safety. S2 stated R1 would come downstairs and be confused as to why R1 came downstairs, R1 would not remember where R1's apartment was located, and R1 would stay in the dining room after eating meals and tell staff that no one talked to R1 and R1 did not eat yet. S2 stated R1 was also found outside at 3:00 AM/4:00 AM by staff. S2 stated after that incident, the private companion services was offered. S2 stated R1 saw his/her primary care physician, where he/she was diagnosed with a neurocognitive disorder. S2 stated reported that R1 has expressed liking the private companion because the resident can go on walks 3-4 times a day, goes to activities, and has been eating and drink fluids regularly.

Based on a review of R1’s progress notes: on August 18, 2023, stating FM1 and R1’s Case manager met to discuss next step with R1’s new condition.

Based on a review of R1’s Physician’s Report dated February 23, 2023, R1 had mild cognitive impairment.

Based on a review of R1’s Physicians report dated August 18, 2023, R1 has a neurocognitive disorder.

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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: 06/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20230919081904

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: 06/27/2025

NARRATIVE

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Based on a review of R1’s admission agreement dated February 28, 2023, R1 does not have any noted responsible party. Furthermore, the Admission agreement states, on page 4, “if you begin receiving a different level of care, this is a new service and the rate for the new level of care shall be charged immediately.

Based on a review of R1’s file, R1 had a durable power of attorney, which was executed on October 10, 2023. FM1 is not listed as the durable power of attorney. Moreover, a review of R1’s private care giver services continued after the establishment of the power of attorney, until November 2, 2023.

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.

Page 5 Out of 5. 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: 06/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025

LIC9099 (FAS) - (06/04)

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