435202807-10-8-2025-26-AS-CKAI-DM9VDS-20251008162113

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202807
Report Date: 10/08/2025
Date Signed: 10/08/2025 04:21:27 PM

Document Has Been Signed on 10/08/2025 04:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR/ DIRECTOR:	GOLDEN, KIM		FACILITY TYPE:	740
ADDRESS:	1420 CURCI DRIVE		TELEPHONE:	(408) 283-0941
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95126
CAPACITY: 150		CENSUS:	DATE:	10/08/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:55 PM
MET WITH:	Ida Gemignani-Stearns, General Manager		TIME VISIT/ INSPECTION COMPLETED:	04:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. The purpose of this visit is to deliver the final report on a case management that was initiated on 09/19/2025 regarding a death report received on 08/12/2025 for former resident (R1). LPA met with General Manager, Ida Gemignani-Stearns. On 08/12/2025, the Department received a death report stating that on 08/11/2025 at approximately 09:30am, a staff went to give R1 medications and found R1 unresponsive. In the report, it was stated that the resident was noted to have some confusion on 08/08/2025 and 911 was called but resident refused to be transferred for further evaluation. 4 staff members were interviewed. Based on staff interview, R1 was not under hospice care and resided in assisted living. R1 was only receiving medication management and housekeeping once a week but was independent for other care needs. According to the staff, the last time R1 was checked was during the night before his/her passing during bedtime medication pass. Since R1 wasn't a resident who required care, staff were not required to check R1 throughout the night unless R1 called for assistance. Staff members who observed R1 that night before his/her passing did not report anything unusual with R1’s condition. R1’s responsible party was interviewed. Based on the interview, it was stated that R1 had many health conditions which may have contributed to his/her passing. It was stated that leading up to R1’s passing, R1 was already not feeling well but refused to go to the hospital. Page 1 of 2.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/08/2025

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R1’s responsible party stated that the facility responded right away and called 911 upon discovering R1. R1’s cause of death is unknown at this time but R1’s responsible party does not feel there was any foul play or neglect from the facility.

Based on record review, R1 had multiple health conditions. Facility staff noted the observation of R1 not feeling well on 08/07/2025. Staff tested R1 for COVID and the results were negative. R1 did not report any pain. The review of records show that R1 was monitored the next day and no changes of condition was noted. Based on R1’s care plan, R1 did not require any assistance with activities of daily living to include bathing, dressing, grooming, transferring and toileting.

Based on R1’s responsible party, the cause of death based on the certificate is unknown as of 09/19/2025.

No further follow-up needed at this time, unless new information is presented in the future that warrants this case to be re-opened.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Ida Gemignani-Stearns and a copy of the report was provided.

Page 2 of 2.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025

LIC809 (FAS) - (06/04)

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