435202807-9-17-2024-26-AS-RMAO-D9MRGA-20241001130023

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 09/17/2024
Date Signed: 09/17/2024 05:18:21 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
01/13/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220113142014

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: 89	DATE:	09/17/2024
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Karen Nickolai - GM		TIME COMPLETED:	11:56 AM

ALLEGATION(S):

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Residents’ care needs are not being met
Staff not providing residents with food of good quality
Resident charged for services not received.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) conducted an unannounced investigation visit to deliver an amended investigation report and met with General Manger (GM) Karen Nickolai.

On 7/9/2024, Licensing Program Analyst (LPA) Steve Chang delivered the investigation findings report and met with General Manger (GM) Karen Nickolair.
On 01/13/2022, the Department received a complaint with the above allegations.
On 1/21/2022, the Department conducted an initial investigation visit and met with the prior General Manager (PGM) Corinne Gies. Due to the facility having COVID outbreak on 1/21/2022, LPA interviewed PGM at the facility backyard. LPA requested resident Physician's Report, Functional Capability Assessment, Admission Agreement, Housekeeping schedule, staff schedule, food menu, and emergency call log and maintenance log.

Continue on LIC9099-C. Page 1 of 4.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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 4

Control Number 26-AS-20220113142014

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: 09/17/2024

NARRATIVE

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Resident care needs are not being met:
The allegation is that resident R1 does not receive timely showers and the garbage does not get taken out timely.

On 12/13/2023, LPA interviewed resident R1. R1 stated he/she rejected the facility's shower service and caregivers' every two hours checking to reduce the monthly payment due to his/her budget concern. R1 stated he/she pays the facility monthly payment by self and wants to reduce the facility monthly payment. R1 stated he/she hires a private caregiver to come in his/her room 3 days per week to help his/her care needs. R1 stated he/she requests the private caregiver to provide 3 showers per week for him/her, to clean his/her room, and to take out the trash from his/her room.

R1 stated he/she goes to supermarket to buy food and eats meals in his/her room. R1 stated the facility housekeepers come to clean the room one time per week and take out the trash.

LPA interviewed 3 residents. 3 Out of 3 residents stated the facility housekeepers clean their rooms at least one time per week. 3 out of 3 residents stated they have at least 2 showers per week. 2 Out of 3 residents stated caregivers take out the trash when they visit the rooms. 3 Out of 3 residents stated they don't have any complaint against the facility.

LPA interviewed previous General Manger (GM1). GM1 stated resident R1 refused the facility shower service, caregivers' checking on R1, and facility meal service to reduce his/her monthly payment. GM1 stated R1 eats the meals in his/her room. GM1 stated R1 hires a private caregiver to help R1's care needs and to clean R1's room.

On 05/23/2024, LPA interviewed 7 residents. 7 Out of 7 residents stated the housekeepers clean the rooms at least one time per week. 7 Out of 7 residents stated they have at least 2 showers per week.

LPA interviewed GM1. GM1 stated the facility already communicated with R1 that the facility policy is that residents need to receive the care and supervision provided by the facility.

Continue on LIC9099-C. Page 2 of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 26-AS-20220113142014

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: 09/17/2024

NARRATIVE

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Based on the interviews, R1 refused the care and services provided by the facility to reduce R1's monthly payment, and refused to pay the facility's care and service. R1 hired a private caregiver to provide him/her care. R1 declined to use the facility's service and hired a private caregiver.

Staff not providing residents with food of good quality:

On 12/13/2023, LPA interviewed resident R1. R1 stated he/she refused the facility meal service to reduce the monthly payment due to the his/her budget concerns. R1 stated he/she pays the facility monthly payment by self. R1 stated he/she goes to supermarket to buy food for meals. R1 stated he/she just came back from the supermarket for grocery shopping and showed LPA the food he/she bought. R1 stated he/she just finished lunch in the room by having breads and drinks that he/she bought.

LPA observed the food R1 bought from supermarket were stored in the room for R1's meals.

LPA interviewed previous General Manager (GM1). GM1 stated R1 refused the facility meal service to reduce the monthly payment and eats meals in his/her room.

LPA interviewed 2 residents. 2 out of 2 residents stated the facility food is good. Both stated they do not have any complaint for the food service.

On 05/23/2024, LPA interviewed 8 residents. 7 out 8 residents stated the facility food is good and without any complaint for the food service, and 1 out 8 stated the facility food is not very good but is acceptable.

Based on the interviews, resident R1 refused the facility meals service to reduce the monthly payment and bought food from supermarket and had the meals in the room. R1 did not use the meals provided by the facility.

Continue on LIC9099-C. Page 3 of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20220113142014

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: 09/17/2024

NARRATIVE

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Resident charged for services not received:
The allegation is that the facility did not refund the money for resident's stay in hospital for 4 days.

On 12/13/2023, LPA interviewed R1. R1 stated he/she was in hospital from 12/7/21 to 12/10/21 and did not receive facility service during the 4 days time period.

LPA interviewed previous General Manager (GM1). GM1 stated based on the facility policy, the facility will refund the money if resident was in hospital for more than 14 days.

On 05/23/2024, LPA interviewed R1. R1 stated after he/she communicated with the facility and he/she understands that the facility will refund the money if residents out of the facility for more than 2 weeks.

Based on the document review, R1's signed Residency and Service Agreement dated 1/29/2021, there is no description regarding the refund for resident's hospitalization. A review of current facility Residency and Service Agreement dated May 2024, it specifies "When you have been away from your Apartment for 14 consecutive days, credit for Assisted Living Services will be given beginning on day 15 until you return."

The Department has investigated the above allegations. Based on the investigation, observations, records reviewed, and interviews conducted, the Department found that the above allegations are UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No deficiencies were cited per California Code of Regulations, Title 22.

Exit interview was conducted with GM. This report was provided to GM for signature. A copy of the report was provided to GM.

Page 4 of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC9099 (FAS) - (06/04)

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