435202350-9-25-2023-26-AS-KHOS-CW8GSK-20231002053602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202350
Report Date: 09/25/2023
Date Signed: 09/25/2023 12:39:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2020 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20201217135141

FACILITY NAME:	BELMONT VILLAGE SAN JOSE		FACILITY NUMBER:	435202350
ADMINISTRATOR:	GILDA DEOCARES		FACILITY TYPE:	740
ADDRESS:	500 S WINCHESTER BLVD		TELEPHONE:	(408) 984-4767
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	150	CENSUS: 110	DATE:	09/25/2023
		UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Gilda Deocares		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident sustained an injury from a fall while in care
Staff did ensure a resident consumed an appropriate amount of fluids while in care
Staff did not follow resident's medical orders

INVESTIGATION FINDINGS:

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12/29/2020

On 09/25/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Director of Resident Care Services, Gilda Deocares and explained the purpose of today's visit.

Regarding the allegation, resident sustained an injury from a fall while in care, it was reported that resident (R1) was sent to hospital after a fall and injuring the head.

According to Reporting Party (RP), he/she was made aware by a caregiver that R1 was sent to the hospital. RP noticed that R1 had a bump in the head but days later the face was bruised, but since has faded. Based on record reviews, an incident report on 12/18/2020 was sent to CCLD that R1 was sent to hospital due to an unwitnessed fall. LVN was alerted through an electronic monitoring system in the facility. 911 was called and upon further assessment by paramedics, R1 was brought to hospital for further evaluation. In this report it was also stated that R1 tried to get up from the wheelchair and fell, R1 claimed that his/her head was hit.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

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-20201217135141

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: BELMONT VILLAGE SAN JOSE	FACILITY NUMBER: 435202350
	VISIT DATE: 09/25/2023

NARRATIVE

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Based on interviews conducted, R1 was in continuous monitoring even if there is an electronic monitoring system in place. There was also a follow up video appointment that staff assisted the resident. Incident was reported to the POA, although POA advised that if another family member asks then facility can provide information regarding R1s health status.

Regarding the allegation, staff did ensure a resident consumed an appropriate amount of fluids while in care, it was reported that facility failed to read client's discharge paperwork which provided specific instruction for staff to monitor client's liquid intake and output.

Based on records review, R1 was found to be dehydrated as reported in the discharge papers form the said hospital visit. According to staff interviews, they were not aware that R1 was dehydrated. Staff constantly offer different types of hydrations to residents. There are a variety of fluids apart from water that they offer such as juices and cold jello. Since R1 is in memory care, staff offers constant hydration since residents tend to forget to drink if not offered or made aware.

Regarding the allegation that staff did not follow resident's medical orders, it was reported that R1 was dehydrated, and facility was not following this order.

Facility only has one medical order given to them by the doctor. There were no previous orders that facility needed to follow. Based on record reviews, after discharge from hospitalization, it was ordered that R1 needs to hydrate, and that facility needed to keep track of food and fluid intake.

Therefore, based on the interviews conducted, files reviewed, and information collected, the allegations mentioned are UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed and a copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC9099 (FAS) - (06/04)

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