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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 06/09/2023
Date Signed: 06/09/2023 12:36:25 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
05/24/2023 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20230524134414
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: 84DATE:
06/09/2023
UNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Will CarterTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Staff do not respond to resident's call for assistance in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced complaint investigation visit to deliver findings on the above allegation. LPA met with facility General Manager Will Carter (Admin).

During review of facility call logs LPA observed that between the period of May 22nd 2023 to June 2nd 2023, the facility had a call response time of over 45 minutes 71 times. Call logs with a wait time of over 45 minutes occurred 15 times on the week of the 29th, and 56 times on the week of the 22nd. Average wait time for calls during this period was 8 minutes. Longest wait time observed that was confirmed via interviews to be a non-accidental call was 2 hours and 41 minutes.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
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-20230524134414
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: 06/09/2023
NARRATIVE
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During interviews with facility residents 4 out of 6 residents interviewed stated that they had been made to wait an unusually long amount of time after pressing call button or pulling call strings. During interview with Admin, Admin stated that the facility had issues with simultaneous call ins for sick days during the week of May 22nd that resulted in understaffing for the week. Admin stated that the facility has since revised it's sick leave policy requiring staff calling in sick to confirm coverage with other staff members. Additionally Admin is in the process of hiring additional staff, including three new hires to the caregiving team that are currently on-boarding.

The Department has conducted an investigation of the above allegation. Based on records review and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiency cited. See LIC 9099-D. Exit interview conducted with General Manager Will Carter. A copy of this report, along with the facility's appeals rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20230524134414
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: 06/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/16/2023
Section Cited
CCR
87411(a)
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87411 - Personnel Requirements - (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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Facility to conduct a mandatory inservice all-staff training regarding response to calls in a timely manner and interfacing with call buttorns. Facility continues the process of hiring new staff. Facility to provide POC and weekly call logs by due date.
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Based on records review and interviews, facility staffing levels were not high enough to meet the needs of residents between 05/22 and 06/02. This presented a potential risk to the health and safety of residents in care.
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3