435200727-9-17-2021-26-AS-RMAO-C79SGG-20210927135155

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200727
Report Date: 09/17/2021
Date Signed: 09/17/2021 01:40:52 PM

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
03/17/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20210317094839

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: 131	DATE:	09/17/2021
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	SHANTELA YADAO, ED		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff threatened to hit the resident in care.

INVESTIGATION FINDINGS:

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LIcensing Program Analyst (LPA) Steve Chang conducted a complaint investigation visit to deliver investigation finding.

On 3/17/2021, the Department received a complaint of the above allegation. On 03/22/2021, LPA conducted an investigation. LPA met with Administrator (ADM), two staff(S1-S2) and resident (R1). The facility LIC500, Personnel Summary, were obtained.

Continued, see LIC 9099-C, pages 2 of 3

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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-20210317094839

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: 09/17/2021

NARRATIVE

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Staff threatened to hit the resident in care:

On 03/18/2021, the Department received an incident report from facility about R1 stating that someone hit R1 and R1 did not feel safe in facility.

On 03/19/2021, LPA Chang conducted a phone interview with R1’s responsible party (RP). RP stated R1 has dementia and at times confused. RP stated does not believe that facility staff had physically abused R1. RP stated there was a video camera installed inside R1's room, but there was no footage showing staff hitting R1 or anything suspicious.

On 03/22/2021, 03/23/2021, and 05/06/2021, LPA interviewed 5 staff (S1 - S5) and ADM. ADM stated that on 03/13/2021 ADM became aware of R1’s allegation that ‘someone hit R1 and R1 doesn’t feel safe.” ADM stated that R1 stated that the incident occurred weeks ago and unable to name staff member but named all morning staff as the person who hit R1 with a rolled-up newspaper. ADM stated that allegation of physical abuse was reported to law enforcement agency. ADM stated that R1 did not report any injuries. On the same day, staff (S1-S5) were interviewed. All of them stated that they did not hit or threaten R1. 5 Out of 5 staff stated they did not see or hear any staff threatened to hit R1.

On 3/22/2021, LPA interviewed R1. R1 was not able to provide the detail information of the alleged incident due to neurocognitive disorder.

Continued, see LIC 9099-C, pages 3 of 3

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20210317094839

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: 09/17/2021

NARRATIVE

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The department has investigated the above allegations. Based on the investigation, observations, records 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 allegations did or did not occur.

No deficiencies or 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 emailed to ED.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3