435200727-11-21-2022-26-AS-RMAO-CLE6BQ-20221121194018

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200727
Report Date: 11/18/2022
Date Signed: 11/21/2022 08:24:54 AM

Unfounded

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
05/25/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20210525142801

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: 92	DATE:	11/18/2022
		UNANNOUNCED	TIME BEGAN:	11:16 AM
MET WITH:	Shantela Yadao		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not address a resident's change in level of care.
Staff did not provide adequate care and supervision to a resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint investigation visit to deliver investigation findings.

On 05/25/2021, the Department received complaint allegations that staff did not address a resident’s change in level of care and staff did not provide adequate care and supervision to a resident.

On 06/04/2021, LPA interviewed Former Executive Director (ED) Jennell Revera and obtained R1’s Physician's Report dated 11/17/2020, Functional Capability Assessment Form and Care Plan, 5/21/2021.

On 10/29/2021, LPA interviewed current Executive Director (ED) Shantela Yadao, and Director of Memory Care Maricel Ong (S1). Copies of Incident reports of R1 were also obtained during visit.

Continued, see LIC 9099-C, pages 1 of 3.

Unfounded

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: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

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-20210525142801

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: 11/18/2022

NARRATIVE

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Staff did not address a resident's change in level of care:
Staff did not provide adequate care and supervision to a resident:

On 05/19/2021, the facility provided a copy of R1’s incident report. The incident report provided information about when R1 was observed bleeding around (her/his) right nipple and noted redness while being assisted with shower. On 05/21/2021, the facility reported that R1 had a fall incident sustaining a skin tear. Staff stated that care and supervision was provided on both days, 05/19/2021 and 05/21/2021.

Per LIC624a (Unusual Incident Report) report, at approximately 630AM on 05/21/2021, R1 was being assisted to the bathroom by S2 when R1’s legs buckled. S2 guided R1 down to the floor but cause R1’s old skin tear opened up and bleed again. First aid was applied, and Hospice Care team and family were informed. A review of R1’s care plan dated 05/21/21, the facility to provide 2 staff to assist R1 with transferring. S1 stated there was no written agreement between the facility and R1’s responsible party regarding 2 staff assist in ADLs.

As a result of R1’s fall incident, a care conference was conducted over the phone with the Hospice team and R1’s responsible party on 5/21, 5/26 and 5/28/2021. All parties involved agreed that R1 to continue comfort and pain management and to keep R1 with 2 persons assist.

A review of R1’s Physician’s Report dated 11/17/2020, R1 had a primary diagnosis of neurocognitive disorder. R1 did not have history of skin condition/breakdown. R1 was not able to manage medications including a PRN order for a Supplemental Oxygen in 2020.

A review of R1’s updated Care Plan dated 05/21/2021, R1 requires assistance in repositioning and requires two staff for transferring. R1 was at risk of skin tears and had swelling upon admission on his/her breast area. R1 had a PRN order for Oxygen Use. R1 was using a Portable Oxygen Tank and O2 Concentrator.

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

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 26-AS-20210525142801

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: 11/18/2022

NARRATIVE

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An interview with the Director of Memory Care (S1), S1 stated that R1 was initially admitted in the Assisted Living Unit and subsequently R1 moved to Memory Care Unit. Due to R1’s declining health, R1 began receiving Hospice Care Services. S1 stated that a two (2) person assist was agreed only for transferring to/from bed/wheelchair while Hospice Agency provided a Home Health Aide (HHA) to help with ADLs such as bathing. S1 stated that facility staff can aid HHA if needed. S1 stated that there is no written agreement between R1’s family and the facility to provide 2 persons assist with ADLs or 1:1 staff for R1.

Based on interviews and record reviews, R1’s level of care indicates that the Hospice Care team and R1’s responsible party were aware of R1’s declining health condition due to terminal illness. The facility assessed and provided an immediate care and supervision when R1 sustained an injury during a fall.

The Department has investigated the above allegations. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegations are 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 was conducted with ED. A copy of this report was provided to ED.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

LIC9099 (FAS) - (06/04)

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