435200727-11-8-2022-26-AS-RMAO-CKZR8P-20221109114814

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200727
Report Date: 11/08/2022
Date Signed: 11/08/2022 12:57:26 PM

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
07/13/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220713121043

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: 92	DATE:	11/08/2022
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Shantela Yadao		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Suspicious death.

INVESTIGATION FINDINGS:

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

On 07/13/2022, the Department received a complaint of suspicious death. On 07/15/2022, the Department conducted an initial investigation visit.

On 9/13/2022, LPA interviewed ED, Memory Care Director Brandee Acosta (S1) and Staff Veronica Chavez (S2).

Continued, see LIC 9099-C, pages 1 of 2.

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: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20220713121043

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: 11/08/2022

NARRATIVE

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Suspicious death:

On 9/8/2022, LPA interviewed family member of R1 (FM). FM stated R1 was on hospice care since April 2020, and did not have any concern about R1's death.

On 9/13/2022, LPA interviewed ED, staff S1 and S2, S1 and S2 stated R1 was on hospice care, and R1 did not respond to stimuli, and R1 had poor food and liquid intake, and was very weak.

On 9/21/2022, LPA interviewed FM. FM stated R1 was severely disabled, bedridden, unable to reposition in bed, and required 24 hours care to assist with ADLs since 2020. FM stated R1 had dementia. FM stated during the past 2 years, R1's doctor was not certain how long R1 would live.

The Department obtained R1's medical records to review, which included LIC624a (Death Report), medical appointment visit notes dates 12/16/2020, and physician letter dated 1/19/2021 and 6/20/2022. Based on the R1's physician's certification for hospice benefit dated on 12/14/2020, R1 has life expectancy of around six months if the terminal illness runs its normal course. Based on R1's certificate of death dated on 07/01/2022, R1's death is due to heart and neurocognitive disorder. On 7/5/2022, the Department received a LIC624a (Death Report) from the facility reporting that R1 died on 7/1/2022 at the facility while under Hospice care. On 1/19/2021, R1's VA medical doctor certified that R1 is no longer capable of making decisions and DPOA will need to be appointed. On 6/20/2022, R1 was seen by geriatric doctor to certify R1 to be placed in facility closer to DPOA/son. The physician discussed R1 being placed under Hospice care.
There was no evidence of neglect or lack of supervision of R1.

Based on the documents reviewed and interviews conducted, R1's cause of death is not suspicious rather R1's death is due to heart and neurocognitive disorder per death report.

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 Executive Director (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: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

LIC9099 (FAS) - (06/04)

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