435202447-4-7-2021-26-AS-RMAO-BZYNAJ-20210411101738

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 04/07/2021
Date Signed: 04/07/2021 12:54:59 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
12/29/2020 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20201229082749

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: 84	DATE:	04/07/2021
		UNANNOUNCED	TIME BEGAN:	11:36 AM
MET WITH:	Marie Harris		TIME COMPLETED:	12:02 PM

ALLEGATION(S):

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1. Resident does not receive assistance in a timely manner.

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 December 29, 2020, the Department received the above allegations against the facility. An initial complaint investigation tele-visit was conducted on January 6, 2021.

Allegations stated that resident (R1) waits up to an hour to receive assistance from facility staff.

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: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

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-20201229082749

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: 04/07/2021

NARRATIVE

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On 01/07/2021, R1 was interviewed. R1 stated that R1 is unable to bear weight on both legs and R1 uses a wheelchair to ambulate. However, R1 needs assistance to transfer from R1's wheelchair to bed and to the toilet. R1 stated that R1 waits 15-20 minutes for staff to come back for R1 after R1 is finished with toileting. R1 stated this happens 2-3 times a week and stated staff responds promptly the rest of the time. R1 denied waiting for over one hour.

On 01/07/2021 at 12:39 PM, LPA tested R1's pendant alarm system unannounced. Staff (S1) responded to R1's room by 12:50 PM. On 03/10/2021 at 12:06 PM, LPA tested resident (R10)'s pendant alarm system and staff responded within 1 minute. On 04/06/2021, LPA tested resident (R11)'s pendant at 4:00 PM and staff responded at 4:07 PM. R9 is a two-person assist and a second staff responded by 4:28 PM.

Facility records including staff schedule from October 2020 to March 2021 were reviewed. Schedule indicates that there are at least 3 caregivers and 1 licensed nurse or medications technician in the morning and afternoon shifts and at least 2 caregivers and 1 licensed nurse in the graveyard shift.

Resident and staff interviews were conducted. 9 out of 9 staff stated that they are able to respond to residents' calls within 5 to 20 minutes. Staff stated that if they are currently assisting another resident when the call is received, other staff members check on the resident to assess the need. 8 out of 11 residents who were interviewed stated staff responds within 5-15 minutes and stated that this is an acceptable wait time. 3 out of 11 residents stated staff responds promptly sometimes and can also take longer than 30 minutes to respond on some days, depending on the staff that is on duty.

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.

This report was discussed with Executive Director and a copy 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: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

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
12/29/2020 and conducted by Evaluator Gladys Kuizon

COMPLAINT CONTROL NUMBER: 26-AS-20201229082749

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:	04/07/2021
		UNANNOUNCED	TIME BEGAN:	11:36 AM
MET WITH:			TIME COMPLETED:	12:02 PM

ALLEGATION(S):

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1. Facility staff does not assist resident with bathing and toileting needs.
2. Staff member does not effectively communicate with 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 December 29, 2020, the Department received the above allegations against the facility. An initial complaint investigation tele-visit was conducted on January 6, 2021.

Allegations stated that facility staff does not bathe resident (R1) and does not assist R1 with toileting needs. Furthermore, allegation stated that facility management does not return R1's calls.

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: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

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-20201229082749

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: 04/07/2021

NARRATIVE

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On 01/07/2021, R1 was interviewed. R1 stated that R1 is unable to bear weight on both legs and R1 uses a wheelchair to ambulate. However, R1 needs assistance to transfer from R1's wheelchair to bed and to the toilet. R1 stated that R1 is always assisted by staff to use the toilet and showers. R1 stated R1 does not have complaints about grooming and showering. R1 is able to groom and shower self and staff only assists to transfer R1 to and fro the bathroom.

Regarding staff not responding to R1's phone calls, R1 stated that there had been a change of management and Executive Director (ED) in the facility. R1 confirmed that the new ED has met with R1 and answered all of R1's questions regarding R1's billing statement. R1 cannot remember the date of the meeting.

Resident and staff interviews were conducted. 9 out of 9 staff stated they have not witnessed any resident's hygiene and toileting needs being neglected. Staff, S1 and S2, stated they have personally assisted R1 with toileting needs. 10 out of 10 residents who were interviewed stated staff assist them with their needs, including toileting and showers. 2 out of 10 residents stated the response time needs improvement but staff responds and assists.

This Department has investigated this allegation. Based on interviews conducted and LPA's observation, the Department has found that these allegations are UNFOUNDED, meaning that the allegations are false, could not have happened, and/or is without a reasonable basis.

This report was discussed with Executive Director and a copy 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: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

LIC9099 (FAS) - (06/04)

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