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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202807
Report Date: 11/07/2024
Date Signed: 11/07/2024 01:39:27 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
04/12/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220412103116
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: 88DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:General Manager, Karen NickolaiTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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-Staff are not properly storing medication
-Staff are not properly disposing of medication
-Med Tech Room door is in disrepair
-Facility is not reporting incidents
INVESTIGATION FINDINGS:
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On November 7, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unnannounced complaint visit to deliver the findings for the above allegations. LPA met with General Manager, Karen Nickolai and explained the purpose of the visit.

Regarding the allegation, staff are not properly storing medication, according to the reporting party, the Med Techs at the facility are pulling medication and putting it into pill organizers and left on the table instead of being locked up. In addition, the reporting party indicated that there are medication errors and violations at the facility and stated that if an audit is conducted, there will be discrepancies.

During the visit, LPA interviewed the General Manager at the time, conducted a medication audit and observed the medication room. Based on observations made during the visit conducted on 4/20/2022, LPA observed facility to be pre-pouring medication in plastic organizers or small cups labeled for morning and with bedroom numbers. The medication observed were being dispensed in small cups for 24 to 48 hours in advance. In addition, during medication audit conducted on 4/20/22, LPA and Med-tech observed 8 packs of Acetaminophen in the overstock cabinet to not be logged on the Centrally Stored Medication Record (CSMR). Staff 2 (S2) was not sure why they are not on the CSMR. Based on CSMR review of Resident 1 (R1), LPA observed a medtech initial stating "error" with no explanation to why there is an error on the back of the MAR. Resident's Lotanoprost eye drops were not on the CSMR. According to the General Manager at the time, she was not aware that staff are pre-pouring medication for more than 24 hours and indicated that staff should be aware to only pre-pour medication for no more than 24 hours.
(Continue to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cowan April
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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 8
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
04/12/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220412103116

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: 88DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:General Manager, Karen NickolaiTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
-Resident's medical files are not updated
-Resident was hit by a care staff
INVESTIGATION FINDINGS:
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On November 7, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unnannounced complaint visit to deliver the findings for the above allegations. LPA met with General Manager, Karen Nickolai and explained the purpose of the visit.

Regarding the allegation, resident's medical files are not updated, according to the reporting party, residents' care plans and some medical records are not being properly maintained as residents' physician's reports are not being updated annually and records are not being maintained according to the regulations.

During the investigation, LPA interviewed staff and reviewed six resident files. Based on 6/6 resident records reviewed, all resident records are updated, complete, signed and properly maintained at the facility.

Regarding the allegation, resident was hit by a care staff, according to the reporting party, on 4/7/2022, a Resident 2 (R2) reported being hit by a care staff.

According to the General Manager at the time, there was an incident that occurred on 4/6/22 where R2’s private caregiver reported to the Assisted Living Director at the time that R2 complained of a facility caregiver being abusive. In addition, General Manager at the time indicated she received a statement from the staff member who was assisting R2 and he/she indicated that while helping pull R2’s briefs up, R2 accused the staff of being abusive. Based on files reviewed, R2 has dementia. Facility conducted their internal investigation, and the general manager at the time did not find any signs of abuse or neglect. (continue to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cowan April
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 26-AS-20220412103116
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: 11/07/2024
NARRATIVE
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LPA was unable to interview R2 during the investigation as R2 is no longer at the facility and LPA was unable to interview staff due to the staff involved no longer being employed at the facility.

Based on interviews conducted & records reviewed, the department has determined that although the above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED.

Report is reviewed with General Manager, Karen Nickolai and a copy is provided.
SUPERVISORS NAME: Cowan April
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 26-AS-20220412103116
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: 11/07/2024
NARRATIVE
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Regarding the allegation, staff are not properly disposing of medication, according to the reporting party, the facility is not properly disposing expired medication and is not aware if residents are being administered expired medication by staff.

During the investigation, LPA interviewed staff and observed the medication room. On 4/20/22, LPA observed a bin full of medication that needed to be destructed. According to staff interviewed, the last time the facility properly destroyed medication was on 2/15/22 because the facility has not had a nurse since March of 2022 and the nurse would be the one who would usually destruct the medications with the med-techs or the administrator as witness. In addition, according to the General Manager at the time, staff are supposed to destruct medications weekly however medications that needed to be destructed have not been destructed since 2/15/22 and LPA conducted the complaint visit on 4/20/22. On 11/7/24, LPA observed the medication room and observed a full box of medications that needs to be destructed on the floor.

Regarding the allegation that med-tech room door is in disrepair, according to the reporting party, the Assisted Living med-tech room door is in disrepair, does not lock and is usually propped open, making medication accessible to residents in care.

During the investigation, LPA interviewed the General Manager at the time and observed the Assisted living med-tech room. According to the General Manager at the time, in December of 2021, he/she was made aware that the med-tech room door was in disrepair and contacted third-party contractor, Vortex for a quote, however he/she did not send a confirmation to Vortex to repair the door. In addition, the General Manager at the time indicated, it was not till February 2022 when he/she officially sent an order to get the door repaired. Based on observations during the visit, LPA observed the med-tech room. LPA observed the top door hinge to be loose, a sign on the door stating disrepair and a nail in a ziplock bag from the missing nail on the door hinge. According to observations and interviews, the Med Tech room in assisted living is located inside the assisted living office, which is always locked. If the door is open, there is staff supervising the office and med-room.

Continue to 9099C.
SUPERVISORS NAME: Cowan April
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 26-AS-20220412103116
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: 11/07/2024
NARRATIVE
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Regarding the allegation, facility is not reporting incidents according to the reporting party, on 4/7/2022, resident 2 (R2) reported being hit by a care staff and doesn’t believe the General Manager at the time reported this incident to the state.

LPA interviewed General Manager who indicated that there was an incident that occurred on 4/6/22 where a R2’s private caregiver reported to the Assisted Living Director at the time that R2 complained of a facility caregiver being abusive. The General Manager at the time admitted to not filing an SOC341 because she did not see signs of abuse or neglect after conducting the internal investigation. In addition, the General Manager at the time also admitted to not filing an incident report to CCLD for unknown reasons.

The Department has conducted an investigation of the above allegations. Based on observations, staff interviews and records review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties.

Report is reviewed with the General Manager and a copy is provided with appeal rights.
SUPERVISORS NAME: Cowan April
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 26-AS-20220412103116
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: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2024
Section Cited
CCR
87465(h)(5)
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87465 Incidental Medical and Dental Care:
(h) The following requirements shall apply to medications which are centrally stored:
(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement has not been met as evidenced by:
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Deficiency is cleared and corrected the time of the visit. LPA observed medication room and did not observe any pre-poured medication.
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Based on observations made during the visit conducted on 4/20/2022, LPA observed facility to be pre-pouring medication in plastic organizers or small cups labeled for morning and with bedroom numbers. The medication observed were being dispensed in small cups for 24 to 48 hours in advance. Nevertheless, the facility is transferring residents' medications from the originally received container to small cups.
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Type B
11/14/2024
Section Cited
CCR
87465(h)(6)
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87465 Incidental Medical and Dental Care:
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes...

This requirement is not met as evidenced by:
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Licensee/administrator shall conduct training with med-techs to ensure all prescribed medications are logged on the CSMR and a record is maintained for each centrally stored medication.
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Based on observations and record review, LPA and Med-tech observed 8 packs of Acetaminophen in the overstock cabinet to not be logged on the Centrally Stored Medication Record (CSMR). In addtion, LPA observed R1's eye drop not logged on the CSMR.
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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: Cowan April
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 26-AS-20220412103116
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: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2024
Section Cited
CCR
87465(i)
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87465 Incidental Medical and Dental Care: (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident...
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Licensee/administrator shall submit a plan on how to ensure medications that require destruction is destructed so the destruction box isn't full or overfilling. Plan shall include company being used for destruction (if any), protocols, process, and how often.
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Based on observations, on 4/20/22, LPA observed a bin full of medication that needed to be destructed. In addition, on 11/7/24, LPA observed a full box of medications that needed to be destructed.
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Type B
11/14/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation:
(a) The facility shall be clean, safe, sanitary and in good repair at all times...

This requirement is not met as evidenced by:
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Deficiency is cleared and corrected during the visit. LPA observed med-tech room to be in good repair.
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Based on observations LPA observed the top door hinge to be loose, a sign on the door stating disrepair and a nail in a ziplock bag from the missing nail on the door hinge. In addition, based on interviews conducted, it was indicatd that the door has been in disrepair for more than 2 months.
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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: Cowan April
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 26-AS-20220412103116
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: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements:
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D) below...

This requirement is not met as evidenced by:
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Licensee/administrator shall submit a plan in writing on how the facility will ensure all incidents that occur at the facility will be submitted to CCL within regulatory requirements.
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Based on interview conducted with the General Manager at the time, there was an incident that occurred on 4/6/22 where R2 complained of a facility caregiver being abusive. The General Manager at the time admitted to not filing an incident report to CCLD for unknown reasons which poses a potential health and safety risk for 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.
SUPERVISORS NAME: Cowan April
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8