435202447-3-26-2021-26-AS-RMAO-BZKLX5-20210329090809

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 03/25/2021
Date Signed: 03/26/2021 12:30:44 PM

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
11/06/2020 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20201106171220

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: 75	DATE:	03/25/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Marie Harris		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff did not properly assess resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gladys Kuizon conducted a complaint tele-visit today to deliver investigation findings. LPA met with Executive Director Marie Harris. Due to COVID-19 restrictions, facility visits have been suspended.

On November 6, 2020, the Department received the above allegations against the facility. An initial complaint investigation tele-visit was conducted on November 13, 2020.

Allegation stated that resident (R1) was not properly assessed by facility prior to adding 24-hour one-on-one caregiving services to R1.

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: 03/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

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 5

Control Number 26-AS-20201106171220

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: 03/25/2021

NARRATIVE

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Resident records and written correspondences were obtained and reviewed. The investigation revealed that resident (R1) and representatives signed an Assisted Living Admission Agreement in January 2018. Based on a Personal Service Plan assessment dated January 26, 2018, R1 was oriented to person, place and time, and can communicate needs and preferences.

Subsequent Personal Service Plan assessments were conducted by the facility for R1 on January 18, 2019, August 14, 2019, and March 24, 2020. R1's Physician's Report dated July 9, 2020 showed a new major neurocognitive disorder diagnosis. On August 5, 2020, facility progress notes showed that R1 was observed confused and disoriented to place.

Investigation revealed that a meeting was conducted by the facility on August 19, 2020 to discuss R1's care plan. R1's responsible party (RP) attended the meeting. Discussion about R1's new diagnosis was discussed. RP requested more testing from R1's doctor to confirm R1's new major neurocognitive disorder.

Staff interviews were conducted. 7 out of 7 staff stated residents are assessed by facility nurse or their personal doctor for any changes in their care plans. LPA reached out to 11 random residents in Assisted Living. 5 residents agreed to be interviewed. 5 out of 5 residents stated they are regularly seen by their doctors and facility nurse assesses their needs.

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 with Executive Director. 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: 03/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
11/06/2020 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20201106171220

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: 75	DATE:	03/25/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Marie Harris		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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9

1. Facility charged resident for services not agreed upon.
2. Staff removed resident's personal property without permission.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gladys Kuizon conducted a complaint tele-visit today to deliver investigation findings. LPA met with Executive Director Marie Harris. Due to COVID-19 restrictions, facility visits have been suspended.

On November 6, 2020, the Department received the above allegations against the facility. An initial complaint investigation tele-visit was conducted on November 13, 2020.

Allegations stated that resident (R1) was charged for a private caregiver without R1's agreement. R1 also had personal property removed from R1's room without R1's permission.

Facility records and correspondence records from reporting party (RP) were obtained and reviewed.

Continued, see LIC 9099-C, page 2 of 3.

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: 03/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

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 5

Control Number 26-AS-20201106171220

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: 03/25/2021

NARRATIVE

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Investigation revealed that a meeting was conducted by the facility on August 19, 2020 to discuss R1's care plan. R1's responsible party (RP) attended the meeting. Discussion about R1's new major neurocognitive disorder diagnosis, as indicated on a July 9, 2020 Physician's Report, was discussed. Facility informed RP that R1 will need to move to the facility's Memory Care unit or be provided a one-on-one caregiver to remain in the facility's Assisted Living unit due to safety concerns regarding R1's current living environment. RP requested more tests from R1's physician to confirm R1's diagnosis.

On August 20, 2020, records showed the facility's Assisted Living Director (ALD) sent an email titled "Follow up from today's call" to RP informing RP that a one-on-one caregiver will be provided to R1 in Assisted Living until further notice due to R1's current room unit not being safe for someone with a major neurocognitive disorder.

Records showed that R1 was provided a one-on-one caregiver 24-hours a day from August 21, 2020 to September 4, 2020 10:00 AM through a third party, licensed home care organization.

R1's signed Admission (Residency) Agreement was reviewed. Residency Agreement stated on Page 3, "If the Community determines, in our sole discretion, that it is necessary to provide you with one on one care in order to protect your health and safety or the health and safety of others, the Community will arrange for such care and you will be charged the market rate of a third party companion."

Staff interviews were conducted. 1 (S1) out of 4 staff caregivers who were interviewed stated they remember seeing a small table in R1's room but is unsure whether the table was transferred out of R1's room with or without permission. A review of R1's records revealed that an antique table is not listed in R1's inventory of personal belongings. The facility's theft and loss policy states on page 4, "The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory."

LPA reached out to 11 residents in Assisted Living. 5 residents agreed to be interviewed. 4 out of 5 residents stated they have not had any personal items lost and not found in the facility.

Continued, see LIC 9099-C, page 3 of 3.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20201106171220

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: 03/25/2021

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 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.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5