435202807-7-14-2025-26-AS-RMAO-DJY3X6-20250726183749

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 07/14/2025
Date Signed: 07/14/2025 03:36:54 PM

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
12/05/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20231205101721

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: 82	DATE:	07/14/2025
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Administrator Ida Gemignani-stearns		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff smoking marijuana at the facility
Staff are charging residents for services not rendered

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 December 5, 2023, the Department received a complaint alleging Staff smoking marijuana at the facility.

On December 15, 2023, LPA Christine Dolores conducted the initial complaint investigation visit.

LPA Dolores interviewed staff S2-S5. S2- S4 stated they have never heard or seen staff members smoking marijuana. Staff S5 stated he/she has heard about a staff member vaping but doesn’t want to get involved.

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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: 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 12

Control Number 26-AS-20231205101721

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 Dolores interviewed resident R1-R5. Residents R1-R5, stated they haven’t observed staff smoking marijuana inside the facility.

On May 28, 2025, LPA Manuel Monter interviewed residents R6-R12. All residents interviewed denied stated they have never seen staff smoking/consuming drugs/ Alcohol and never seen staff working while intoxicated.

LPA Monter interviewed facility ADM. ADM stated she has never seen staff smoking/consuming drugs/ Alcohol. ADM stated she has never seen staff working while intoxicated.

On May 28 and June 6, 2025 LPA Manuel Monter interviewed staff S6-S11. All staff interviewed stated they have not seen staff smoking/consuming drugs/ Alcohol and never seen staff working while intoxicated.

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.

Staff are charging residents for services not rendered

On December 5, 2023, the Department received a complaint alleging Staff are charging residents for services not rendered. It has been alleged that resident R1 is being charged for services not rendered.

On December 15, 2023, LPA Dolores interviewed resident R1. R1 states he/she is being charged for dressing and toileting but he/she is not receiving these services consistently. R1 states he/she does not receive these services sometimes. R1 states he’s not being billed properly.

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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: 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 12

Control Number 26-AS-20231205101721

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 Dolores interviewed Staff S1. S1 stated R1 owes them for care services. S1 stated he/she doesn’t agree that they are not providing R1 services that are rendered. S1 stated R1 owes an outstanding balance and R1 has not been willing to pay the outstanding balance just pays rent and care he/she thinks he/she should be receiving. S1 stated R1 only wants to be charged for toileting services. S1 stated, previously it was dressing like compression socks that were on his/her care plan and they had to charge for those services, adding up to R1’s outstanding balance. S1 stated R1 doesn’t want to pay for showers and says he/she can do it on his/her own. S1 stated Care staff will assist him/her with showering sometimes.

On February 27, 2024, the Department interviewed staff S12. S12 stated Dena stated that R1 has not paid his/her rent for the past 2 years and currently for this month of March 2024 only, owes about $11k. S12 stated the facility has reached out to R1’s family member and provided him/her the invoice ledger but never responded to them. S12 stated that the community complies to R1;s request but disagree with allegation that they are overcharging him/her for services not rendered to him/her.

On May 28, 2025, LPA Manuel Monter interviewed residents R6-R12. Resident R6, R7, R12 stated he/she has been getting assistance with their ADL’s and there hasn’t been a time when they have not been assisted with their ADL’s. R8- R11 stated he/she doesn’t need assistance with their ADL’s.

LPA Monter interviewed facility 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.

On May 28 and June 6, 2025, LPA Manuel Monter interviewed staff S6-S11. S6-S11 stated staff assist residents with their activities of daily living. S6-S11 stated there hasn’t been a time when residents haven’t been assisted with his/her ADL’s.

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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: 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 12

Control Number 26-AS-20231205101721

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 Monter conducted a review of facility records (Rental/Care Fee monthly ledger) regarding resident(R1). Upon review, LPA found that R1 was admitted to the facility starting 1/27/2021. Within the first months of R1's admission to the facility, R1 had a total fee of $9730.79 with a waived community fee resulting in an updated total of $$7329.79. With the fees added the following month, R1's due amount totaled to $16,920.79. During the statement period of March 2021, R1 had only paid $6636.67 by check. The charges included (rent to end of January, February and March 2021, level of care 5, parking, pendant replacement) Since admission, R1 had an outstanding amount of fees owed to the facility. In addition, R1 would not pay the full amount from additional monthly charges. From the initial owed payment/fees, R1 had also acquired late fees and failed to pay total due amounts, which ultimately added to R1's total outstanding amount.

Based upon department conducted interviews with residents there were no indications that staff were not meeting resident level of care needs. Interviews with former Executive Director (S1) and Business Office Manager (S12) indicated that R1 had been admitted to the facility in January 2021. Based upon review of R1’s payment ledger for rental and care fees, LPA found that R1 had outstanding fees owed to the facility. As a result, additional late fees accrued which increased the total amount of R1's total fees owed.

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: 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 12

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
12/05/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20231205101721

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: 82	DATE:	07/14/2025
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Administrator Ida Gemignani-stearns		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident left in soiled bedding/clothing
Staff are not repositing resident
Staff are not administering medication(s) to resident(s) as prescribed

INVESTIGATION FINDINGS:

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On December 5, 2023, the Department received a complaint alleging a resident left in soiled bedding/clothing. / Staff are not repositing resident. It has been alleged that resident R5 was left in soiled bedding/clothing and isn’t being repositioned.

On December 15, 2023, LPA Christine Dolores interviewed Staff S2-S5. S2, S3 stated they found R1 soiled and wet. S2 stated he/she hasn’t had to reposition R5 in the morning because usually he/she’s in the wheelchair. S2 stated R1 moves him/herself a lot if they need to reposition him/her. S3 stated they don’t reposition R5 in bed. S4 stated he/she doesn’t provide care for R5 and has not observed him/her. S5 stated he/she has not seen R5 left soiled and states R5 is being repositioned.

Page 1 Out of 4.

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: 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 12

Control Number 26-AS-20231205101721

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 Dolores interviewed residents R1-R5. R1 stated he/she doesn’t need assistance with repositioning in bed. R2 and R4 stated they don’t need assistance with repositioning or toileting. R3 stated he/she is ambulatory and doesn’t need assistance with repositioning.

R5 stated no one comes to reposition him/her. R5 stated staff comes to early to assist him/her in changing his/her cloths in the morning. R5 stated he/she has been left soiled diapers. R5 stated it can take up to an hour to get to him/her to change him/her.

On May 28, 2025, LPA Manuel Monter interviewed residents R6-R12. Residents R6- R11 stated he/she hasn’t seen other residents’ bedrooms as dirty, disrepair or with foul odors. Residents R6 -R12 stated they have not seen residents who were left soiled for an extended period. R6 stated he/she does need assistance in being changed and has not had any issues. Residents R7 -R12 stated he/she doesn’t need assistance in being changed.

Residents R6, R7, R12 stated they get assistance with their ADLs and there hasn’t been a time when they were not assisted with their ADL’s. Residents R8-R11 stated they don’t need assistance with their activities of daily living.

LPA Monter interviewed facility ADM. ADM stated he/she has not seen any residents who were left soiled for an extended period. ADM stated staff assist resident with repositioning. ADM stated if it part of their care plan, then staff will reposition them every 2 hours or more if needed.

On May 28 and June 6, 2025 LPA Manuel Monter interviewed staff S6-S11. Staff S6-S11 stated residents who need to be repositioned, are repositioned every 2 hours.

Staff S6, S8, S10, S11 stated they have not found resident who were left soiled for an extended period. Staff S7 S9 stated he/she has found residents who were left soiled from the previous shift.

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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: 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 12

Control Number 26-AS-20231205101721

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 toured the facility. LPA toured all the resident bedrooms in the memory care unit (1-13) and observed the bedrooms as clean and in good repair. LPA toured the following bedrooms in the assisted living section of the facility: 111, 132, 229, 219, 303, 316, 412,427. The bedrooms observed in assisted living were 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.

Staff are not administering medication(s) to resident(s) as prescribed

On December 5, 2023, the Department received a complaint alleging Staff are not administering medication(s) to resident(s) as prescribed.

On December 15, 2023, LPA Christine Dolores conducted the initial complaint investigation visit.

LPA Dolores interviewed staff S2-S5. Staff S2, S3 and S5 stated they doesn’t handle residents’ medications. Staff S4 stated he/she has been administering resident medications as prescribed and had no misses.

LPA Dolores interviewed resident R1-R4. Resident R1, R2, R3 stated he/she handles his/her own medication. Resident R4 stated he/she gets her medications daily without any issues.

On May 28, 2025, LPA Manuel Monter interviewed residents R6-R12. Residents R6, R10, R12 stated he/she has been getting his/her medication daily without any issues. Residents R7-R9, R11 stated they handle their own medication and do not need staff assistance for medication administration.

LPA Monter interviewed facility ADM. ADM stated he/she residents are getting his/her medication on time. ADM stated there are no issues regarding residents getting their medication. ADM stated she is not aware of any issues or delays regarding medication administration.
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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: 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 12

Control Number 26-AS-20231205101721

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 and June 6, 2025 LPA Manuel Monter interviewed staff S6-S11. Staff S6, S8 and S11 stated residents are getting their medications daily, per physician’s order. Staff S7 stated there has been times when medications that need to be administered in the morning were administered several hours later. S9 stated there has been times when residents didn’t get their medication or was given the incorrect medication. S10 stated he/she knows that a medtech at the facility is making medication.

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 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.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
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 12

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
12/05/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20231205101721

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: 82	DATE:	07/14/2025
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Administrator Ida Gemignani-stearns		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff are not ensuring facility is free from pests

INVESTIGATION FINDINGS:

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On December 5, 2023, the Department received a complaint alleging Staff are not ensuring facility is free from pests. It has been alleged that resident R1’s bedroom has cockroaches.

On December 15, 2023, LPA Christine Dolores interviewed resident R1-R5. R1 stated he/she has observed cockroaches and fruit flies inside his/her apartment. R2-R5 stated they haven’t seen pests in their apartment.

LPA Dolores interviewed staff S2-S5. Staff S2 & S4 stated they have not seen pests in residents bedrooms. Staff S3 stated resident R1’s bedroom sometimes has cockroaches. S5 stated 4 resident bedrooms have cockroaches.

Page 1 Out of 3.

Substantiated

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: 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: 9 of 12

Control Number 26-AS-20231205101721

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 8, 2024, LPA Simi Rai interviewed Former administrator Will Carter, referred to as S1. S1 stated he/she has reached out to Orkin since facility has an existing contract. S1 stated they have used Orkin to thoroughly cleaning of resident's apartment. S1 stated cockroaches will come back after treatment since resident leaves food out in the room. S1 stated Orkin has been 4 times for R1’s bedroom. S1 stated R1 has allowed housekeeping to come once a week to clean his/her room and he/she has not refused any service.

LPA Rai interviewed facility Maintenance Director (MD) Ollie Moor Jr. MD stated the pests issues have been ongoing for a year. MD stated the facility staff always clean R1’s room and the pest control folks go into R1’s room for treatment. MD stated R1 leaves food around and had conversations about leaving food around. MD stated there is regular housekeeping once a week. MD stated they will clean the room further so the issue isn't persistent, but the issue are the days that housekeeping doesn't come into the room.

LPA Rai interviewed staff S6. S6 stated there has been a long-standing issue with roaches in R1’s apartment. S6 stated R1 has not refused to have housekeeping come in the room. S1 stated there always is a bag of candy and there are always wrappers near R1’s wheelchair on the floor so the sweet candy is attracts the cockroaches.

On May 28, 2025, LPA Manuel Monter interviewed residents R6-R12. Residents R6-R12 stated they haven’t seen cockroaches or pests in the facility.

LPA Monter interviewed ADM. ADM stated R1’s room had cockroaches, but she hasn’t seen them. ADM stated the facility has had exterminators come out to address the issue.

On May 28 and June 6, 2025 LPA Manuel Monter interviewed staff S7-S11. S7 stated he/she hasn’t seen any pests inside the facility. S8 stated he/she has seen many cockroaches and ants in the kitchen. S9 stated he/she has observed ants in the memory care kitchen. S10 stated he/she has seen cockroaches in R1’s bedroom and a bedroom adjacent to R1’s bedroom. S11 stated he/she observed cockroaches in the memory care unit. S11 stated she has brought up this issue to management, but management has not addressed it. S12 stated there was a report in November 2024, that the memory care unit of the facility had cockroaches. S12 stated they have hired pest control, which addressed the issue.
Page 2 Out of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
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: 10 of 12

Control Number 26-AS-20231205101721

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 11, 2025, LPA Manuel Monter interviewed Staff S1. S1 stated due to R1’s condition R1 had difficulty cleaning up for him/herself. S1 stated R1 did not have any behaviors that would cause his/her bedroom to become dirty. S1 stated they were aware of R1’s troubles with being able to clean up for him/herself. S1 stated they also offered additional housekeeping for R1. S1 stated R1’s family member was also informed about the infestation. S1 stated R1 declined additional housekeeping services. R1 stated he/she didn’t want to pay for additional charges.

S1 stated In April 2024, they did ask orkin to treat the apartment. S1 stated this was where they needed to vacate the entire apartment, and the room had to be empty for 8 hours.

Based on record review, the facility has a contract with Orkin. The service agreement states, “Orkin agree to provide Pest control service (Control means the periodic eradication of existing infestations within practical limits) for control of the following pests: Roaches, ants, silverfish, rats & mice.”

Based on records reviewed, the facility has invoices for Orkin services from January 2023- December 2024.

Based on the investigation, although the facility maintained a contract with Orkin for regular pest control services, it did not ensure R1’s bedroom was free of cockroaches. This posed an immediate health, safety and personal rights risk to R1 and other residents in the facility.

Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Administrator Ida Gemignani-stearns . A copy of the report was provided. Appeal rights were 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: 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: 11 of 12

Control Number 26-AS-20231205101721

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: 07/14/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/15/2025 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by;	1 2 3 4 5 6 7	ADM stated she will submit a letter of understanding regarding the regulation. ADM stated she will also submit a plan of action on how to address future pest outbreaks.
	8 9 10 11 12 13 14	Based on record review and interview the licensee did not ensure the facility was free of cockroaches. This poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025

LIC9099 (FAS) - (06/04)

Page: 12 of 12