435202350-12-6-2023-26-AS-JJIN-CYW2YE-20231226164835

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202350
Report Date: 09/19/2023
Date Signed: 12/06/2023 08:06:06 AM

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
02/01/2021 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210201161703

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:	09/19/2023
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Rachel Brown & Allyson Fujii		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

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Staff caused injury to resident.

INVESTIGATION FINDINGS:

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Amended report

On 12/5/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Executive Director Rachel Brown & emory Program Coordinator, Allyson Fujii and explained the purpose of today's visit.

Regarding the allegation of staff causing injury to resident, Licensing received a report regarding a resident (R1) being injured due to a caregiver grabbing R1s arm and causing a bruise.

R1 is a resident that was diagnosed with mixed dementia and has inappropriate and aggressive behaviors. Assistance on transfers and showering is also assessed for R1. R1 is also 99 years old when the allegation was filed.

Based on interviews four out of four staff members mentioned that R1 is always combative and aggressive. When R1 calls for help and as staff approaches to assist, R1 will start kicking. Staff always waits for R1 to calm down due to R1 being agitated or confused before helping again.

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: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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-20210201161703

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: 09/19/2023

NARRATIVE

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Based on record reviews, former administrator (S1) mentioned in a report that R1 has dementia and can go from being very cognitive to cognitively impaired. When asked about a bruising that was reported, R1 didn’t want to tell S1 who caused the bruising. According to a staff member (S2) when they received report regarding this allegation, a safety plan has been put in place for R1. That plan included welfare checks every 30 minutes. It was also stated by the R1s responsible party (RP) that R1 does not get along with caregivers which is why R1 was moved from a previous facility. R1 was also placed with preferred caregivers after the reported incident. According to R1s medication list, there is nothing prescribed that could have caused resident to easily bruise.

Therefore, based on the interviews conducted, files reviewed, and information collected, the allegation that staff caused injury to resident is UNSUBSTANTIATED, meaning that although the allegation 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: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

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