435202350-8-11-2022-26-AS-SYIP-CKQSV8-20221031141220

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202350
Report Date: 08/11/2022
Date Signed: 08/11/2022 09:51:26 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
10/02/2020 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20201002133323

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: 99	DATE:	08/11/2022
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Natalie Barman		TIME COMPLETED:	09:55 AM

ALLEGATION(S):

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Facility staff failed to seek resident timely medical attention resulting in resident's untimely death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced visit to deliver the complaint investigation finding regarding the above allegation. LPA met with Administrator Natalie Barman.

The Department review of resident's (R1) medical records on 11/13/2020 noted R1 had been taken to the hospital on 09/01/2020 to be treated for right foot cellulitis. R1's records indicate that R1 was not currently receiving hospice treatment, but the option was being discussed. R1 remained admitted to the hospital on 9/17/2020 until R1’s passing on 09/19/2020. Review of R1's death report indicates that R1 passed away from the same conditions that R1 was admitted for.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

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-20201002133323

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BELMONT VILLAGE SAN JOSE	FACILITY NUMBER: 435202350
	VISIT DATE: 08/11/2022

NARRATIVE

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Review of resident's progress notes indicated that R1 was checked 3 times the day R1 was sent to the hospital on 09/17/2020. At 06:00 AM, overnight staff noted scratches below R1's hip that required itch relief, but no other changes in condition were noted. The next entry in progress notes was noted at 02:15pm, in which med tech noted no change of condition, but that R1 had complained of pain. Tylenol was administered as PRN. The final entry in R1's progress notes were recorded at 05:10pm, detailing a change of condition occurring at 03:30pm. It was noted that R1 was measured with an oxygen saturation of 60%, 911 call was made, R1 was brought to the hospital and admitted for clinical impressions of septic shock and gangrenous foot.

In interviews with facility staff, 2 out of 10 facility staff stated that R1's condition had begun to deteriorate hours before the facility agreed to have R1 sent to the hospital. 8 out of 10 facility staff interviewed were unaware of or did not receive any report of change in R1's condition prior to staff check in at 3:30pm, 911 call was made shortly thereafter. 3 out of 3 AM shift staff interviewed stated that there was no change of condition observed or reported on 09/17/2020 during the AM shift. In interview with R1's responsible party (RP), RP stated that they have no reason to believe that R1 received neglectful care from the facility. RP stated that R1 was receiving care from both facility staff and home health agency and facility sent R1 to the hospital when they noticed the change.

This Department has investigated the above allegation. Based on interviews and records review, the Department found that the above allegation is 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 allegation did or did not occur.

This report reviewed and signed by Administrator Natalie Barman and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC9099 (FAS) - (06/04)

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