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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 08/06/2025
Date Signed: 08/06/2025 12:22:11 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
05/13/2025 and conducted by Evaluator Grace Donato
COMPLAINT CONTROL NUMBER: 26-AS-20250513090207
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: DATE:
08/06/2025
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility staff did not properly store resident's medication.
INVESTIGATION FINDINGS:
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On 8/6/2025, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with General Manager Ida Gemigani and explained the purpose of this visit.

Regarding the allegation of Facility staff did not properly store resident's medication, Reporting party (RP) stated that a Med Tech (S3) recently provided resident (R1) with insulin pen for self-administration. After R1 completed the injection, S3 reportedly took the insulin pen and put it in his/her pocket before going to provide medication to another resident (R2). The next day, another Med Tech (S2) found the insulin pen on the floor of R2s, which the RP stated likely fell out of S3s pocket while assisting R2. The RP emphasized that S3 should have returned the pen to the medication cart instead of keeping it in his/her pocket.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 26-AS-20250513090207
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: 08/06/2025
NARRATIVE
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LPA interviewed staff members. S1 mentioned that the insulin pen was given to him/her by S2 so that it will be endorsed to S3. S2 stated that during a shift, does not remember exactly when, the insulin pen was not in the med room but remembers that there was still enough shots in the pen. S2 asked S3 where the pen is and S2 mentioned that it might have fallen from his/her pocket. S2 found the insulin pen in R2s room when he/she was giving eye drops to the resident.

Based on interviews, the above allegation is determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiency may result in civil penalties.

Report is reviewed and copy of report and appeals rights are provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20250513090207
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: 08/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2025
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Licensee shall conduct training with med-techs to ensure all prescribed medications are locked in place. Licensee to submit proof of in-service training to LPA by POC deadline.
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This was not met as evidenced by:
Based on interviews, S2 mentioned an insulin pen, medication for R1 was found in R2s room, which poses an immediate Health, Safety, or Personal Rights risk to persons 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.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
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