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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 03/26/2021
Date Signed: 03/30/2021 01:38:10 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
12/03/2019 and conducted by Evaluator Yatfai Ng
COMPLAINT CONTROL NUMBER: 26-AS-20191203094801
FACILITY NAME:BROOKDALE SAN JOSEFACILITY NUMBER:
435202447
ADMINISTRATOR:MICHELE MERRITTFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:153CENSUS: 89DATE:
03/26/2021
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Claudia Elias TIME COMPLETED:
09:39 AM
ALLEGATION(S):
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Facility staff failed to seek appropriate medical attention in a timely manner
INVESTIGATION FINDINGS:
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**This is an amended report that was originally delivered on 3/26/2021. The finding remained the same**

Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent complaint tele-investigation to deliver the finding due to current COVID-19 situation. LPA virtually met with the Memory Care Director Claudia Elias.

An initial unannounced investigation was conducted by LPA on 12/09/2019. LPA obtained copies of R1’s physician’s report, R1’s medical notes, and residents roster. LPA interviewed residents and staff. A subsequent investigation was conducted by LPA on 01/09/2020. LPA obtained R1’s progress notes, interviewed residents and staff. On 1/10/2020 and 01/29/2020, LPA conducted 2 phone interviews to 2 staff.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
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 3
Control Number 26-AS-20191203094801
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: 03/26/2021
NARRATIVE
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Between 12/09/2019 and 01/09/2020, 8 residents were interviewed with 6 results. 6 out of 6 residents stated that they did not see facility staff failed to seek appropriate medical attention in a timely manner in their observations and experiences.

Between 12/09/2019 and 01/29/2020, 8 staff were interviewed. Staff interviewed denied delaying the 911 call, however, staff were unable to identify the time of 911 call. Facility also could not produce the call log to verify the time of call despite numerous requests.

Based on the review of the unusual incident report submitted by the facility, it was noted that staff found R1 to have left side face drooping and slurred speech around 11:40 PM on 11/29/2019. The review of San Jose Fire Department’s dispatch record noted that 911 was called at 00:24:56 on 11/30/2019. Ambulance arrived on scene at 00:32:00. Per record review, there was a 44 minute gap from the time R1 was noted to have symptoms of possible stroke to the time of 911 call.

Thus based on record reviews, the preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED, which means that the allegation did occur.

A deficiency was cited today as per California Code of Regulations, Title 22. See 9099-D for more information. Failure to correct the deficiencies may result in civil penalties.

This report was reviewed and emailed to Memory Care Director Claudia Elias for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20191203094801
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2021
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 911 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Licensee agreed to conduct staff training on emergency procedure and to submit the training schedule to CCL by POC due date.
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This requirement was not met as evidenced by: Based on review of incident report and dispatch report from San Jose Fire Dept., there was a 44 minutes gap between the time resident (R1) was observed to have a possible stroke and the time of 911 call. This posed an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3