435200727-5-13-2020-26-AS-RMAO-BPLKY5-20200514081832

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200727
Report Date: 05/12/2020
Date Signed: 05/13/2020 09:27:42 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/23/2019 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20191223115523

FACILITY NAME:	CARLTON PLAZA OF SAN JOSE		FACILITY NUMBER:	435200727
ADMINISTRATOR:	JENNELL REVERA		FACILITY TYPE:	740
ADDRESS:	380 BRANHAM LANE		TELEPHONE:	(408) 972-1400
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	183	CENSUS: 140	DATE:	05/12/2020
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Jennell Revera		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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A third-party contractor handled resident in a rough manner.
Staff humiliated resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Tele-Visit to deliver the complaint investigation findings. Due to the Corona Virus 2019 Disease, the Department has suspended on-site inspections at this time. LPA discussed this report with Jennell Revera.

On 12/23/2019 CCDS received the complaint allegations as follows: Third party contractor handled resident in a rough manner and Staff humiliated resident.

On 1/2/2020 Licensing Program Analyst (LPA) Natkarn Shugan arrived unannounced to conduct a 10 day initial complaint investigation. LPA Shugan interviewed three staff (S1-S3), two residents R1 and R2, and one third-party contractor, hair stylist, (HS). Individual Service Plan, Assessment, and Physician's Report were obtained for three residents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

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 3

Control Number 26-AS-20191223115523

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CARLTON PLAZA OF SAN JOSE	FACILITY NUMBER: 435200727
	VISIT DATE: 05/12/2020

NARRATIVE

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On 1/27/2020 Licensing Program Analyst (LPA) Natkarn Shugan arrived unannounced to conduct a subsequent complaint investigation. LPA Shugan interviewed five staff (S3-S8) and five (R3-R7) residents. On 2/3/2020 a sixth resident (R8) was interviewed by telephone.

On 04/29/2020 and 05/11/2020, LPA Marybeth Donovan interviewed R1 by telephone. On 5/6/2020 and 5/12/2020 LPA Donovan conducted follow up interviews with staff S3 and S8.

Based on available information gathered, sometime in November 2019, a third party contractor (hair stylist-HS) was alleged to have handled R1 roughly wherein third party contractor grabbed R1 by the shirt and pulled R1’s shirt down exposing R1’s undergarment, and told R1 that R1 was being a nuisance. Also, a staff S8 embarrassed and humiliated R1 and would not let R1 get on the facility bus.

Every Sunday the facility offers a scenic drive for interested residents departing at approximately 1:30pm. One Sunday morning R1 was to join a scenic drive wherein the facility driver was late. R1 was told by staff S8 that “people who talk out here don’t get on the bus…. People who are disruptive do not get on the bus and this bus is for seeing not talking.” R1 was told by unidentified staff that there was room on the bus. R1 understood that R1 could go on the scenic ride.

On 04/29/2020 and 05/11/2020, LPA Donovan interviewed R1 by telephone. Based on the information gathered, R1 had a hair appointment scheduled at 10:00am around Thanksgiving Day (November 2019). R1 was approached by hair stylist (HS) in the dining area around 9:00am to inquire if R1 was available before R1’s scheduled appointment at 10:00am. HS proceeded to lower the top of R1’s shirt trying to locate a call pendent to call for someone to take R1 to the hair salon.

On 01/02/2020, LPA Shugan interviewed hair stylist (HS). HS is an independent contractor. HS stated that the incident took place at the dining area. HS stated that R1 wanted immediate help, but HS was not able to assist R1. Instead HS thought it would be best to press R1’s pendant to alert staff to assist R1. HS stated that R1 was in a frantic state looking for help and HS was trying to get help for R1. HS used index finger to pull down about 3-4 inches of shirt from the collar straight down wherein R1’s undergarment was not exposed. HS denies handling R1 roughly and exposing R1’s undergarment.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20191223115523

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CARLTON PLAZA OF SAN JOSE	FACILITY NUMBER: 435200727
	VISIT DATE: 05/12/2020

NARRATIVE

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On 5/6/2020, LPA Donovan interviewed staff S8 and S8 stated that the facility offers a free scenic drive every Sunday at 1:30pm which is on a first come first served basis and there is a waiting list for cancellations. The facility bus can only accommodate 14 passengers plus 1 wheelchair space. S8 recalled an incident with resident R1 wherein another resident R8 had signed up and decided not to go. R8 told R1 that R1 could take R8’s spot. S8 explained to R1 that although R8 had told R1 to take the spot; they have to follow facility’s procedures and policies by going through the waiting list. S8 stated that R1 was not on the waiting list. S8 informed R1 that R1 was not able to go and not getting on the bus. S8 stated that R1 was very upset. S8 denied allegation of speaking to R1 in a manner to humiliate or embarrass R1.

On 1/2/2020 and 1/27/2020 LPA Shugan interviewed eight residents (R1 to R8). On 04/29/2020 and 05/11/2020 LPA Donovan conducted follow up interviews with R1. Seven of these residents R2-R8 do not have any direct knowledge of any situation in which a third-party contractor handled R1 in a rough manner. Two residents R3 and R4 do not utilize optional services such as salon services. Six residents R2 to R7 interviewed were unaware of a situation in which any resident or R1 was humiliated or embarrassed by staff and would not let R1 get on the facility bus. R8 did not provide a response regarding the scenic outing event.
On 1/2/2020 and 1/27/2020, LPA Shugan interviewed eight staff. Six of eight staff (S1, S2, S4-S7) interviewed did not have any direct knowledge of a situation in which any staff or individual handled R1 in a rough manner or embarrassed or humiliated R1.

On 5/6/2020 and 5/12/2020 LPA Donovan conducted follow up interviews with staff S3 and S8. Two out of eight staff S3 and S8 deny embarrassing or humiliating R1 while in their care and supervision.

The Department has investigated the above complaint allegations. Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22.

Report reviewed with Jennell Revera and a copy of this report emailed to Ms. Revera for signature purposes.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

LIC9099 (FAS) - (06/04)

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