435202350-9-25-2023-26-AS-KHOS-CW8H2L-20231002054854

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202350
Report Date: 09/25/2023
Date Signed: 09/25/2023 12:41:48 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
12/29/2020 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20201229100834

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:	11:15 AM
MET WITH:	Gilda Deocares		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Staff did not protect resident from physical abuse.

INVESTIGATION FINDINGS:

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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, staff did not protect resident from physical abuse. It was reported that the resident (R1) sustained bruising that looked like fingers while being under the care of a private caregiver (P1). P1 also locks R1s room which is not allowed.

Based on record reviews, an earlier report was sent to CCLD on 12/14/2020 regarding the bruising on R1s forearms found by another private caregiver (P2). R1 is taking medication that makes skin more conducive to bruising. After the report was also received by the responsible party (RP), RP requested the agency to provide a different private caregiver who can be more suited for the R1s care needs.

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-20201229100834

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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According to interviews conducted, once facility was made aware of the bruising, P1 wasn’t allowed to care for R1, and was requested to leave the facility. This was also with request from RP. There was constant monitoring with R1 and this was the only incident reported while resident was under care of P1. It was also stated in interviews that, P1 was made aware of not locking the door of the room. It was a onetime incident and didn’t happen again. Even if the resident room is locked, Med Techs or other caregivers in the facility can still enter due to them having keys to resident rooms.

Therefore, based on the interviews conducted, files reviewed, and information collected, the allegation that staff did not protect resident from physical abuse 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: 09/25/2023

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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