435200727-9-18-2024-26-AS-KHOS-DA5KAH-20241017074359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200727
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:38:14 PM

Unsubstantiated

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
07/11/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20230711083943

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:	02:13 PM
MET WITH:	Shantela Yadao		TIME COMPLETED:	03:24 PM

ALLEGATION(S):

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Staff did not adequately supervise resident resulting in resident sustaining a fracture while in care.

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 7/11/2023, the Department received a complaint with the allegation that staff did not adequately supervise resident resulting in resident sustaining a fracture while in care.

On 7/18/2023, the Department conducted an initial investigation visit. LPA interviewed 4 staff and requested Resident physician report, Appraisal Needs and Service Plan, Incident Reports.

Continue on LIC9099-C. Page 1 of 3.

Unsubstantiated

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-20230711083943

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 did not adequately supervise resident resulting in resident sustaining a fracture while in care:
On 7/18/2023, LPA interviewed Executive Director Assistant (S1). S1 stated resident R1 can walk in the facility by self without help. S1 stated R1's family member, POA, agreed to place R1 in the facility assisted living unit. S1 stated R1 was assessed by the facility nurse and was admitted in the assisted living unit.

S1 stated R1 had a fall in his/her bedroom on 5/28/2023, and was sent to hospital. S1 stated the facility sent the incident report to CCL office. S1 stated R1 was transferred to another facility after discharging from the hospital.

LPA interviewed Director of Resident Services (S2). S2 stated R1 did not have pendant call button service to call or notify staff. S2 stated on 5/28/2023 around 8:00AM, R1 was found on the floor of his/her bathroom by a caregiver. S2 stated a facility nurse was noticed and came to evaluate R1 and R1 was sent to hospital. S2 stated R1 usually gets up around 7:00AM by self.

LPA interviewed a caregiver (S3). S3 stated R1 behaved normally as usual before the incident. S3 stated on 5/28/2023, around 6:15AM, he/she checked R1 and found R1 was sleeping in the bed as usual. S3 stated R1 lived in a single room and usually gets up self without any help. S3 stated on 8/28/2023 around 8:00AM, he/she found R1 was on the floor of his/her bathroom. S3 stated he/she called thee nurse immediately, and thee nurse came to evaluate R1 immediately. S3 stated the nurse called 911 and R1 was sent to hospital.

Based on the review of R1's incident report, on 5/28/2023 around 8:00AM, R1 was found on the floor of his/her bathroom and complained about pain on the left hip. R1 was sent to hospital. R1 sustained left hip fracture.

Based on the interviews and record reviews, R1 usually gets up by self without any help and R1 was checked by staff twice within 2 hours from 6:15AM - 8:00AM. R1's fall on 5/28/2023 is a unwitnessed fall. The facility staff called 911 immediately after found R1 was on the floor, and R1 was sent to hospital.

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-20230711083943

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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Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

No citations noted for today’s visit. Exit interview was conducted with ED. 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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