435200727-9-18-2024-26-AS-KHOS-D9LQPW-20240930122125

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200727
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:36:55 PM

Unfounded

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
05/15/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20230515102040

FACILITY NAME:	CARLTON PLAZA OF SAN JOSE		FACILITY NUMBER:	435200727
ADMINISTRATOR:	SHANTELA YADAO		FACILITY TYPE:	740
ADDRESS:	380 BRANHAM LANE		TELEPHONE:	(408) 972-1400
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	183	CENSUS: 136	DATE:	09/18/2024
		UNANNOUNCED	TIME BEGAN:	01:06 PM
MET WITH:	Shantela Yadao		TIME COMPLETED:	02:57 PM

ALLEGATION(S):

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Staff are not administering resident's medication per physician's order.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Shantela Yadao.

On 5/15/2023, the Department received a complaint that the facility staff are not administering resident's medication per physician order.

On 5/24/2023, the Department conducted an initial investigation visit. LPA interviewed ED, Executive Assistant, Director of Resident Care, Medication Manager, resident R1 and R1's family member(FM).

LPA requested Resident's discharge documents, doctor prescriptions, physician report, Appraisal Needs and Service Plan, May 2023 Medication Administering Records (MAR).

Continue on LIC9099-C. Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

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 3

Control Number 26-AS-20230515102040

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: CARLTON PLAZA OF SAN JOSE	FACILITY NUMBER: 435200727
	VISIT DATE: 09/18/2024

NARRATIVE

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Staff are not administering resident's medication per physician's order:

On 5/24/2023, LPA interviewed Executive Director (ED). ED stated Med Techs administer medications to residents. ED stated Med Techs will retry 3 times if residents refuse the medications. ED stated Med Techs will document and report if residents refuse medications.

LPA interviewed Director of Resident Service (S1). S1 stated resident R1 does not have any incident of missing medications.

LPA interviewed Executive Assistant (S2). S2 stated he/she is not aware of that R1 has incident of missing medications.

LPA toured resident room and interviewed resident R1. R1 was unable to exactly answer the questions. R1's family member (FM) stated R1 has neurocognitive impairment and he/she can help to answer the questions. LPA interviewed FM. FM stated on 5/7/2023 evening, he/she gave a bottle of medication to a staff (unknown name) in the facility hallway. FM stated based on R1's discharge document, the medication should be administered to R1 starting 5/8/2023. FM stated on 5/8/2023, he/she found the medication in the storage/medication room. FM stated on 5/8/2023, he/she met and talked to a nurse (S3) and the facility started to administer the medication to R1 on 5/13/2023. FM stated the facility did not administer the medication to R1 from 5/8/2023 to 5/12/2023.

LPA interviewed Medication Manager (S4). S4 stated R1 does not have incident of missing medications. S4 stated the system does not have the medication for R1 from 5/8/2023 to 5/12/2023. S4 stated the system has the medication starting 5/13/2023, and the MAR shows the medication was administered to R1 starting 5/13/2023. S4 stated only nurses and medication manager can input the medications into the computer system. S4 stated Med Techs administer medications to resident based on the medication information in the computer system. S4 stated the medication for R1 was entered in the computer system on 5/13/2023, and was administered to R1 staring on 5/132023. S4 stated he/she did not receive any report that the facility received R1's medication on 5/7/2023.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20230515102040

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: CARLTON PLAZA OF SAN JOSE	FACILITY NUMBER: 435200727
	VISIT DATE: 09/18/2024

NARRATIVE

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LPA interviewed staff S3. S3 stated resident's family member cannot just bring the medication to the facility for resident. S3 stated the facility needs doctor's order or prescription to administer medications to resident. S3 stated even the over the counter medication that family member brings in for resident, the facility also needs the doctor order for resident. S3 stated R1's family member saw the medication (over the counter) in the medication room but not starting to administer medication to R1 is that the facility was requesting for resident's doctor or prescription for resident R1.

Based on the interviews and document review, the facility did not receive the doctor order for the medication for R1 before 5/13/2023. The facility started to administer the medication to R1 starting from 5/13/2023..

The Department has investigated the above allegations. Based on the investigation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview conducted with Executive Director (ED). This report was provided to review and for signature. A copy of this report was provided to ED.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

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