435202447-4-14-2021-26-AS-RMAO-C29VHA-20210420162648

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 04/14/2021
Date Signed: 04/14/2021 04:18:09 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
01/14/2021 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210114151506

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:	04/14/2021
		UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Marie Harris		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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1. Facility charges resident for services not agreed upon.
2. Facility provides inadequate food service for 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 January 14, 2021, the Department received the above allegations against the facility. An initial complaint investigation tele-visit was conducted on January 25, 2021.

Allegation stated that facility does not provide appropriate food portions for resident (R1) and that the facility served R1 spoiled milk. Additionally, facility continued to charge R1 a two-person assist service for 2 extra months after R1's need has changed.

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

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: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

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-20210114151506

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: 04/14/2021

NARRATIVE

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Allegation 1: Facility charges resident for services not agreed upon:

Interviews were conducted. R1 stated that in June 2020, R1 was hospitalized due to a spinal injury. Upon R1's discharge to the facility, R1 agreed R1 needed a two-person assist through August 2020. However, the facility continued to charge for the months of September and October 2020.

The facility's Financial Services Director (S1) was interviewed. S1 stated that S1 has reviewed and explained the billing statement charges with R1 as some charges may appear a month later on the statement depending on the printing cycle and when the latest assessment was conducted. If the assessment was done after the statement has been printed for that month, any change in the billing will be reflected on the next statement. S1 and Executive Director (ED) met with R1 prior to R1 moving out of the facility to answer R1's billing questions. R1, ED, and S1 confirmed this during separate interviews.

LPA reviewed facility records including R1's billing statements and personal service plan assessments. Records revealed that on June 4, 2020, R1 was assessed as needing a second person or a mechanical lift to help with transfers. For this month, the facility prorated this new service and charged R1 for 27 out of 30 days only. Billing statements showed R1 was charged for the two-person assist service for July and August 2020.

For the month of September 2020, R1 was sent an invoice prior to the beginning of the month showing no rate change from August 2020. On September 7, 2020, a new personal service plan assessment was conducted for R1 which showed R1 no longer needs a two-person assist service. On October 12, 2020, records showed the facility credited R1 back the charges for the two-person assist service as reflected on the September 7, 2020 assessment.

Based on records, R1 was not charged the two-person assist service for the months of September and October 2020.

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: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20210114151506

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: 04/14/2021

NARRATIVE

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Allegation 2: Facility provides inadequate food service for resident:
On March 10, 2021 at 11:44 AM, a tour of the facility was conducted. The facility's main kitchen and food storage were inspected. Perishable and non-perishable foods were observed labeled and stored in a safe and healthful manner. Assisted Living kitchens on the 1st and 2nd floors were also inspected and observed consistent with the facility's food labelling and storage procedures. Individual milk cartons and dairy products were inspected and observed to be at least 7 days from expiration date.

The director of dining services (S2) was interviewed. According to S2, milk is delivered to the facility daily and facility consumes dairy products at a rate that is faster than its expiration date or shelf life.

Residents were interviewed. 10 out of 10 residents stated they have never been served spoiled food. All residents stated that food portions are sufficient for them and they are able to request more if they want to. Resident (R1) was interviewed. R1 stated that R1 is a big person and facility provides R1 with small portions of food. R1 confirmed that R1 can ask for second servings and staff provides it. R1 stated there is no problem with the food and the quality. R1 stated that R1 thought R1 was served spoiled milk once but R1 did not check the expiration date on the carton.

Staff were interviewed. 10 out of 10 staff stated they have never observed spoiled food being served to residents. All staff stated residents are provided extra servings if needed and residents may request for snacks in between meals.

This Department has investigated these allegations. Based on interviews conducted, records reviewed, 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 are 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: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

LIC9099 (FAS) - (06/04)

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