435202447-3-1-2021-26-AS-KHOS-BYYPNJ-20210310102802

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 02/26/2021
Date Signed: 03/01/2021 10:21:12 AM

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
10/28/2020 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20201028152039

FACILITY NAME:	BROOKDALE SAN JOSE		FACILITY NUMBER:	435202447
ADMINISTRATOR:	ODETTE COLONDRES TORRES		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	153	CENSUS: 69	DATE:	02/26/2021
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Rizaldy Carreon, Assisted Living Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not report an unusual incident as required.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Gladys Kuizon conducted a complaint tele-visit today to deliver investigation findings. LPA met with Assisted Living Director Rizaldy Carreon via video conferencing. Due to COVID-19 restrictions, facility visits have been suspended.

On October 28, 2020, the Department received the above allegation against the facility. An initial complaint investigation tele-visit was conducted on November 6, 2020.

Reporting Party (RP) was interviewed at 12:14 PM on November 3, 2020 and stated that facility did not inform RP of an unusual incident involving RP's spouse, a resident of this facility, in a timely manner.

The investigation revealed that on October 21, 2020, a facility staff (S1) reported an incident which occurred on October 18, 2020 to facility management.

Continued, see LIC 9099-C, page 2 of 2.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 26-AS-20201028152039

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: BROOKDALE SAN JOSE	FACILITY NUMBER: 435202447
	VISIT DATE: 02/26/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

S1 reported receiving a phone call from resident care associate (S2) during S1's day off on October 18, 2020. S2 was informing S1 that S2 witnessed another resident care associate (S3) slapping resident, R1's, leg while S2 and S3 were changing R1's diapers that day.

S1 reported the incident to facility management the first day S1 was scheduled back to work on October 21, 2020.

Facility records were reviewed and showed that facility sent an incident report to Community Care Licensing and Long Term Care Ombudsman on October 21, 2020. R1's spouse (F1) confirmed receiving a call from the facility on October 21, 2020 informing F1 of the incident and F1 contacted R1's physician to conduct a physical examination of R1. R1's physician visited the facility and completed the physical examination on October 23, 2020.

This Department has investigated this allegation. Based on interviews conducted and records reviewed, the Department has found that this allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and a copy of this report was provided electronically for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
10/28/2020 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20201028152039

FACILITY NAME:	BROOKDALE SAN JOSE		FACILITY NUMBER:	435202447
ADMINISTRATOR:	ODETTE COLONDRES TORRES		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	153	CENSUS:	DATE:	02/26/2021
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Rizaldy Carreon, Assisted Living Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

1. Facility staff slapped resident.
2. Facility staff left resident in soiled clothing for an extended period of time.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Gladys Kuizon conducted a complaint investigation tele-visit today to deliver investigation findings. LPA met with Assisted Living Director Rizaldy Carreon via video conferencing. Due to COVID-19 restrictions, facility visits have been suspended.

On October 28, 2020, the Department received the above allegations against the facility. An initial complaint investigation tele-visit was conducted on November 6, 2020.

Resident and staff interviews were conducted. 7 out of 8 staff stated that they have not witnessed any co-worker slapping or hitting resident (R1) or any resident. 8 out of 8 staff stated residents' diapers are changed at least every 2 hours.

Continued, see LIC 9099-C, page 2 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20201028152039

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: BROOKDALE SAN JOSE	FACILITY NUMBER: 435202447
	VISIT DATE: 02/26/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed that on October 18, 2020, staff (S1) witnessed staff (S2) slapping R1's legs while S1 and S2 were transferring R1 to bed. S1 reported the incident to staff (S3) who was off that day.

On October 21, 2020, upon S3's return to work, S3 reported the incident to facility management and an investigation was conducted by the facility's human resource (HR) department. S2 resigned from work prior to the conclusion of the investigation. LPA was unable to reach S2 for an interview. LPA interviewed S1 and S3. S1 stated S1 saw S2 hitting R1 with an open hand once on each leg while attempting to change R1's diapers. S1 stated the incident occurred in R1's private room and there were no other witnesses.

R1's spouse (F1) was informed of the incident on October 21, 2020 and F1 contacted R1's primary care physician (PCP) for a physical examination of R1. On October 23, 2020, R1's PCP conducted a physical examination of R1 and did not observe bruises on R1. PCP noted eczema on buttocks area and increased the dosage of R1's current medication for it. PCP notes did not identify cause of eczema.

R1's medical records were reviewed. Per R1's diagnoses, R1 has memory impairment and is not a good historian. R1 is also non-verbal. On February 11, 2021, LPA attempted to interview R1. R1 did not respond. LPA observed R1 awake, slightly reclined to a seated position in bed, and with no visible signs of injury on exposed skin. R1's clothes and bed linens were observed clean and in good repair.

LPA attempted to interview residents in the facility's Memory Care unit where R1 resides. 5 out of 5 residents were unable to respond to interview questions due to cognitive impairment. R1 does not have a room mate.

San Jose Police Department (SJPD) report #20-295-9514 was obtained and reviewed.

The Department has investigated the above allegations. Based on interviews conducted and records reviewed, the Department found that the above allegations are 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.

Exit interview conducted and a copy of this report was provided electronically for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4