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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 07/16/2024
Date Signed: 07/16/2024 10:44:00 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230512153909
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: 95DATE:
07/16/2024
UNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Karen NickolaiTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff neglect resulted in a resident's death
Staff is sleeping while residents are present
INVESTIGATION FINDINGS:
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On 7/16/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with General Manager Karen Nickolai and explained the purpose of today's visit.

Regarding the allegation of staff neglect resulted in a resident's death, RP stated that there was resident (R1) who was not given proper care, R1 passed away because staff was neglectful and R1 did not receive CPR until maybe 30 minutes later when the oncoming shift came and the EMT's came in.

Based on statements obtained, on 03/07/2023, R1 pressed the call button at 5:46am. Staff (S4) responded and cleared the call button alarm at 5:50am. R1 expressed having "abdominal pain" and S4 stated another caregiver would come back to check on R1 since it was the middle of a shift change. S4 informed incoming caregiver (S5) that R1 was experiencing a "stomachache" and S5 told S4 it would take a while before S5 would be able to go check on R1. S4 returned to R1’s room and found R1 unresponsive. S4 contacted 911 at 6:16am and performed CPR until paramedics arrived. R1s death certificate lists cause of death as cardiac arrest.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
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 2
Control Number 26-AS-20230512153909
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: MERRILL GARDENS AT WILLOW GLEN
FACILITY NUMBER: 435202807
VISIT DATE: 07/16/2024
NARRATIVE
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Interviews obtained state that staff are to immediately contact 911 if a resident has fallen, is vomiting, expresses shortness of breath or chest pain, or if they have some sort of severe injury. If a resident is expressing sickness or stomach pain, the facility is to monitor the resident, contact the family and inform the primary care physician. Based on interviews obtained, R1 only reported abdominal pain and never mentioned shortness of breath or chest pain.

Regarding the allegation of staff is sleeping while residents are present, RP stated that the coworker is speculated to be always sleeping, no one knows because he/she cannot be contacted over radio, and

RP even called the company iPhone, and he/she did not pick up the phone.

There were six staff members who were interviewed. One staff (S1) mentioned that Management has tried to come at random times during the night but has never found both staff to be sleeping. Another staff (S3) also mentioned that S3 would show up at the facility at all times of the night and would never catch a staff member sleeping. Another staff (S5) stated that S5 has never seen staff sleeping and has never had any concerns about staff sleeping during their shift. S4 also shared that it's hard for night shift staff to sleep because ''they're so busy." Staff need to respond to resident alarms in less than five minutes. If staff take longer than five minutes, "they need to answer to that." S4 has always responded to pendant alarms as fast as they can. The only time there is a delay is if S4 is currently helping another resident.

Based on interviews & records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation dids or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2