Inspection Reports for Merrill Gardens at Willow Glen

The visit was an unannounced case management - incident visit to deliver the final report on a case management initiated on 2025-09-19 regarding a death report received on 2025-08-12 for a former resident.

The investigation found no deficiencies or evidence of neglect or foul play by the facility. The resident was independent in care needs, had multiple health conditions, and the cause of death was unknown at the time of the report. The facility responded promptly and called 911 upon discovering the resident unresponsive.

The visit was an unannounced case management - incident inspection to follow up on a death report received on 08/12/2025 regarding a former resident.

During the visit, documents including the resident's face sheet, service plan, progress notes, and staff schedule were reviewed, and interviews were conducted with a witness and two staff members. The case management remains open pending further investigation.

The visit was an unannounced case management inspection to amend two previously closed complaint investigations issued on July 14, 2025, specifically to change the findings regarding pest allegations to substantiated due to an erroneous finding on the previous report.

No deficiencies were cited during this visit. The amended findings changed the pest allegations to substantiated based on corrected information from the prior complaint investigations.

The visit amended two complaint investigations (26-AS-20240430134658 & 26-AS-202402131434450) that were closed on July 14, 2025, changing the pest allegation findings to substantiated due to an erroneous finding on the previous report.

An unannounced complaint investigation was conducted due to allegations that the facility had cockroaches in a resident's room.

The investigation found that despite the facility having a contract with Orkin for pest control, cockroaches were present in resident R1's bedroom, posing an immediate health, safety, and personal rights risk. The complaint was substantiated based on interviews and document reviews.

The complaint alleging cockroaches in a resident room was substantiated. The issue was ongoing with multiple reports dating back to 12/05/2023, and subsequent complaints on 02/13/2024 and 04/30/2024 were considered a continuation of the same pest-related allegation.

Licensing Program Analyst Simi Rai conducted a case management visit in response to information received during a complaint investigation.

During the visit, medications for resident R1 were found in a locked office outside the medication room, and the destruction log for R1's medications was not located. The Resident Care Director, responsible for medication destruction and documentation, was not available during the visit. Further investigation was deemed necessary.

The visit was conducted in response to information received during a complaint investigation. Further investigation was determined to be needed.

The visit was an unannounced Plan of Correction (POC) visit conducted to verify correction of a previously cited Type A deficiency during a complaint investigation.

No deficiencies were cited during the POC visit. The facility provided a plan of corrections and a Letter of Deficiencies Cleared letter was issued.

The original deficiency was cited during a complaint investigation visit for complaint number 26-AS-20231205101721. The deficiency was substantiated and corrected with a POC due date of July 15, 2025.

An unannounced complaint investigation was conducted due to allegations that staff did not ensure a resident's unit was free of pests, specifically cockroaches.

The investigation found that despite the facility having a contract with Orkin for pest control services, the resident's bedroom was not free of cockroaches, posing an immediate health, safety, and personal rights risk. The allegation was substantiated based on interviews and document reviews.

The complaint alleging staff did not ensure resident's unit was free of pests was substantiated. The complaint was received on 12/05/2023, with subsequent related complaints on 02/13/2024 and 04/30/2024, all considered a continuation of the same pest-related allegation.

The inspection was an unannounced complaint investigation visit triggered by multiple complaints received on 2023-12-05 regarding staff smoking marijuana, charging residents for services not rendered, residents left in soiled bedding/clothing, failure to reposition residents, medication administration issues, and pest infestations.

The investigation found the allegations of staff smoking marijuana, charging residents for services not rendered, residents left in soiled bedding/clothing, failure to reposition residents, and medication administration issues to be unsubstantiated or unfounded. However, the allegation that staff failed to ensure the facility was free from pests, specifically cockroaches in resident R1's bedroom and other areas, was substantiated, posing an immediate health and safety risk.

The complaint investigation was initiated based on multiple allegations received on 2023-12-05, including staff smoking marijuana, charging residents for services not rendered, residents left in soiled bedding/clothing, failure to reposition residents, medication administration issues, and pest infestations. The investigation included interviews with staff, residents, and administrators, facility tours, and record reviews. Most allegations were found to be unsubstantiated or unfounded except for the pest infestation allegation, which was substantiated.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2024-02-13 regarding resident assistance with ADLs, staffing adequacy, foul odors, and medication error reporting, as well as allegations of staff providing care under the influence and making fun of residents.

The investigation found all allegations related to resident assistance, staffing, foul odors, and medication error reporting to be unsubstantiated, meaning there was insufficient evidence to prove the allegations. However, the report was amended to substantiate a prior finding that the facility had cockroaches in a resident room, correcting an earlier erroneous unfounded finding. Allegations of staff working under the influence and making fun of residents were found to be unfounded.

The complaint investigation was unannounced and conducted by Licensing Program Analyst Manuel Monter. Allegations included residents not being assisted with ADLs, inadequate staffing, foul urine odor, failure to report medication errors, staff providing care under the influence, and staff making fun of residents. Interviews with residents, staff, and administration, as well as record reviews and medication audits, were conducted. The majority of allegations were found unsubstantiated or unfounded except for the amended substantiated finding of cockroaches in a resident room.

The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-10-24 alleging multiple issues including facility disrepair, cold food, lack of transportation assistance, staff rudeness, and inadequate accommodations.

The investigation included interviews with residents, staff, and administrators, as well as review of documentation. All allegations were found to be unsubstantiated with no citations issued. Residents and staff consistently reported no issues with food quality, transportation, staff behavior, or facility maintenance.

The complaint investigation was unsubstantiated. Allegations included poor facility repair, cold food, lack of transportation assistance, staff rudeness, and inadequate accommodations. Interviews and documentation review did not support these claims.

The inspection visit was an unannounced case management-incident visit triggered by an Incident Report received on 6/30/2025 regarding a financial theft reported by a resident on 6/26/2025.

No deficiencies were cited during the visit. The Licensing Program Analyst interviewed facility management and a resident, requested additional documentation, and conducted an exit interview with the Senior Resident Care Director.

The complaint involved a financial theft reported by Resident R1 on 6/26/2025. The complaint was investigated during the visit, but no deficiencies were cited.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2023-09-19, including failure to report a resident's fall, failure to ensure resident safety resulting in injury, charging for unauthorized services, and medication administration without a physician's order.

The investigation found all allegations to be unfounded after interviews and records review. The resident's fall was reported appropriately given no responsible party was listed, medication was administered with a valid physician's order, and the facility's charging for private companion services was authorized by the resident despite no family member consent. Overall, the allegations were determined to be false or without reasonable basis.

The complaint investigation addressed allegations that facility staff did not report a resident's fall to responsible parties, failed to ensure resident safety resulting in injury, charged the resident for unauthorized services, and administered medication without a physician's order. The investigation included interviews with staff and the resident, review of progress notes, physician reports, admission agreements, and medication orders. The findings concluded all allegations were unfounded.

The visit was conducted as an unannounced complaint investigation following an allegation received on 2024-02-06 that facility staff were threatening a resident with eviction.

The investigation found the allegations to be unfounded after interviews with staff, residents, and review of records, confirming no threats of eviction were made by facility staff.

The complaint alleged that facility staff were threatening a resident with eviction. After investigation, including interviews with multiple staff members, residents, and review of communications, the allegations were determined to be unfounded.

The inspection visit was an unannounced complaint investigation triggered by allegations received on 2023-06-20 that facility staff slapped a resident and treated the resident in a rough manner.

After interviews with residents, staff, and witnesses, and review of records including law enforcement and medical notes, the allegations were found to be unsubstantiated due to lack of preponderance of evidence to prove the claims.

The complaint alleged that staff slapped resident R1 and treated him/her in a rough manner. Multiple residents and staff denied witnessing such behavior. Witness W1 observed bruises on R1 but believed they may have come from an assistive device. Law enforcement and medical records noted bruising and skin tear but no conclusive evidence of abuse by staff S2 and S3. The investigation concluded the allegations were unsubstantiated.

The inspection was an unannounced complaint investigation conducted in response to complaints alleging that facility staff were not assisting residents with showering, wheelchair transfers, and medication administration as prescribed.

The investigation found the allegations regarding lack of assistance with showering and wheelchair transfers to be unfounded, with residents and staff confirming adequate assistance was provided. The medication administration allegations were unsubstantiated, with some staff reporting occasional delays but no evidence of consistent issues.

The complaint investigation was triggered by allegations received on 11/30/2023 that facility staff were not assisting residents with showering and wheelchair transfers, and not dispensing medications as prescribed. The showering and transfer allegations were found to be unfounded, and the medication administration allegations were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by complaints alleging the facility did not follow physician’s orders when administering medication, increased residents services without proper notice, and charging for services not being provided.

The investigation substantiated two allegations: the facility did not follow physician’s orders regarding medication administration and increased residents services without proper notice. The allegation that the facility charged for services not being provided was found to be unsubstantiated. Deficiencies were cited related to medication administration and failure to provide proper notification of rate increases.

The complaint investigation was substantiated for allegations that the facility did not follow physician’s orders when administering medication and increased residents services without proper notice. The allegation that the facility charged for services not being provided was unsubstantiated.

The inspection was conducted as an unannounced complaint investigation following an allegation that staff were overcharging a resident for services not received.

The investigation found no indication that staff were not meeting resident care needs. Review of payment records showed the resident owed outstanding fees and late fees accrued. The complaint was determined to be unfounded with no deficiencies cited.

The complaint alleged staff were overcharging a resident for services not received, specifically unexplained rental fees. The complaint was investigated and found to be unfounded.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-10-31 regarding allegations about resident care and facility practices.

The investigation found the complaint allegations unsubstantiated after touring the facility, interviewing staff, reviewing records, and making observations. No deficiencies were cited and the allegations were determined to lack sufficient evidence.

The complaint alleged the facility did not provide alternatives to water, failed to provide proper supervision in the memory care dining room, and did not change a resident's diaper. The investigation found these allegations unsubstantiated due to lack of corroborating evidence and observations supporting proper care.

The inspection was an unannounced Annual Continuation visit, continuing the required 1 Year Annual Inspection started on 2024-11-27.

A deficiency was cited due to incorrect prescription numbers on centrally stored medication and destruction records for 5 out of 8 reviewed residents, posing a potential health risk. Resident and staff records were otherwise found to be complete.

The visit was an unannounced case management follow-up regarding an incident report submitted by the facility about a resident accessing and consuming another resident's medications.

The investigation found that the medication tray was left within reach on a kitchen counter and the kitchen swing door was not locked, allowing resident access. A technical violation was issued, but no deficiencies were cited under California Code of Regulations Title 22.

The inspection was an unannounced Required 1 Year visit to evaluate the facility's compliance with regulations.

The Licensing Program Analyst toured the facility, including kitchen, outside areas, bathrooms, and resident living units, and found no deficiencies at this time. The annual inspection will be continued at a later date due to time constraints.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that a resident's call cord was in disrepair.

The investigation found no evidence of damaged call cords after testing multiple resident bedrooms and interviewing staff. The allegation was determined to be unsubstantiated and no deficiencies were cited during the visit.

The complaint alleged that a resident's call cord was in disrepair. The allegation was found to be unsubstantiated due to lack of corroborating evidence.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that the facility did not have proper emergency protocols for wheelchair-bound residents.

The investigation found that the facility had emergency evacuation chairs at each stairwell on the second and fourth floors and did not lack proper emergency protocols for wheelchair-bound residents. The complaint was determined to be unsubstantiated.

Complaint alleged the facility did not have proper emergency protocols for wheelchair-bound residents. The allegation was found unsubstantiated after investigation.

An unannounced complaint investigation visit was conducted in response to allegations received on 05/04/2022 regarding staff children sleeping in the common area and facility plumbing in disrepair.

The investigation found no evidence that staff children slept or ran around the facility, and residents and staff confirmed children were not disruptive. The plumbing issue in the memory care unit was found to have been repaired and was not affecting daily operations. Therefore, the allegations were determined to be unsubstantiated.

The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations regarding staff children sleeping in common areas and plumbing disrepair.

An unannounced complaint investigation visit was conducted in response to multiple allegations including improper medication storage and disposal, disrepair of the med-tech room door, failure to report incidents, outdated resident medical files, and alleged resident abuse.

The investigation substantiated deficiencies related to improper medication storage and disposal, disrepair of the med-tech room door, and failure to report incidents. The allegation regarding outdated resident medical files was unsubstantiated, and the alleged resident abuse was unsubstantiated due to lack of evidence. Several Type B deficiencies were cited with plans of correction due in mid-November 2024.

The complaint investigation was triggered by allegations received on 04/12/2022 regarding medication storage and disposal, med-tech room door disrepair, failure to report incidents, outdated resident medical files, and resident abuse. The abuse allegation was unsubstantiated due to lack of evidence and inability to interview involved parties. The outdated medical files allegation was also unsubstantiated after record review.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-01-13 regarding residents' care needs not being met, staff not providing residents with food of good quality, and residents being charged for services not received.

The investigation found that resident R1 refused facility services including shower, meal service, and care to reduce monthly payments and hired a private caregiver instead. Other residents reported no complaints about care or food quality. The allegation that the facility charged for services not received during a hospital stay was unfounded based on facility policy and agreements. Overall, the allegations were determined to be unfounded.

The complaint was received on 2022-01-13 with allegations that residents' care needs were not met, staff did not provide food of good quality, and residents were charged for services not received. The investigation concluded the allegations were unfounded.

The visit was conducted to deliver an amended investigation report for the complaint control number 26-AS-20220113142014.

No citation was issued during this unannounced visit. The Licensing Program Analyst met with the General Manager, explained the purpose of the visit, and provided a copy of the amended investigation report.

The visit was related to a complaint investigation for control number 26-AS-20220113142014. An amended investigation report was delivered, and no citation was issued.

An unannounced complaint investigation visit was conducted following a complaint received on 2023-05-12 regarding allegations of staff neglect resulting in a resident's death and staff sleeping while residents are present.

The investigation found that the allegation of staff neglect resulting in a resident's death was unsubstantiated based on interviews and records, including the timeline of care provided. The allegation of staff sleeping while residents are present was also unsubstantiated due to lack of evidence and staff interviews indicating no such behavior.

The complaint involved allegations that staff neglect resulted in a resident's death and that staff were sleeping while residents were present. The investigation concluded both allegations were unsubstantiated due to insufficient evidence.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-01-13 regarding unsanitary resident bedrooms and staff not responding to call buttons.

The investigation found that one resident (R1) refused facility housekeeping and call button services to reduce monthly payments and hired private caregivers instead. No other residents reported unsanitary conditions or issues with call button response. The allegations were determined to be unsubstantiated with no deficiencies cited.

The complaint involved allegations that a facility resident bedroom was not sanitary and that staff were not responding to call buttons. The investigation included interviews with residents, prior and current general managers, and observations. The findings concluded the allegations were unsubstantiated due to lack of preponderance of evidence.

An unannounced complaint investigation visit was conducted in response to an allegation that staff do not respond to residents' calls for assistance in a timely manner.

The investigation found that between May 22 and June 2, 2023, the facility had 71 instances where call response times exceeded 45 minutes, with the longest wait time being 2 hours and 41 minutes. Interviews with residents confirmed delays, and the facility acknowledged staffing issues due to simultaneous sick calls. The allegation was substantiated and a deficiency was cited related to insufficient staffing to meet resident needs.

The complaint was substantiated based on records review and interviews. The facility had multiple instances of delayed call response times, confirmed by resident interviews and facility call logs. The facility acknowledged staffing shortages due to sick calls and is in the process of hiring additional staff.

The visit was an unannounced case management investigation related to claims that the facility disallowed visitation during a COVID-19 outbreak in February 2023.

The investigation found no evidence that the facility restricted visitation during the most recent COVID-19 outbreak in 2023. Records and resident interviews indicated visitation was not restricted, although mask-wearing and social distancing were encouraged.

The visit was complaint-related, investigating claims that visitation was disallowed during a COVID-19 outbreak. The claims were not substantiated based on records and interviews.

An unannounced Required 1 Year visit was conducted as part of the annual inspection process.

The facility was toured inside and outside, with observations including visitor screening, PPE supply, food supply, and bathroom hygiene supplies. No deficiencies were cited according to California Code of Regulations Title 22.

The inspection was a pre-licensing visit conducted to evaluate the facility for licensure approval.

The facility was inspected inside and out, with no deficiencies cited. The physical plant was approved for licensure pending final approval by the Centralized Application Bureau. Safety measures, emergency preparedness, medication security, and documentation were all found to be in compliance.