435202447-5-18-2021-26-AS-MDON-C35SV2-20210518141157

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 05/18/2021
Date Signed: 05/18/2021 02:12:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME:	BROOKDALE SAN JOSE		FACILITY NUMBER:	435202447
ADMINISTRATOR:	MARIE HARRIS		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	153	CENSUS: 83	DATE:	05/18/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:45 AM
MET WITH:	Marielouise Harris		TIME COMPLETED:	02:15 PM

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	Licensing Program Analyst (LPA) Marybeth Donovan and Licensing Program Manager (LPM) Gladys Kuizon met with Executive Director (ED) Marielouise Harris for a Case Management visit to follow up on a substantiated complaint regarding neglect/lack of care and supervision. On May 10, 2018, the Department concluded a complaint investigation which alleged that the facility staff did not provide appropriate medical care after observing a pressure injury on a resident (R1). The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87466 Observation of the Resident for failure to regularly observe R1 for changes in physical functioning and when observed, for failure to document the change and bring it to the attention of the physician after the facility had observed the pressure injury. Additionally, the licensee was cited for violating CCR Title 22, § 87211(a)(1)(B) Reporting Requirements for failure to report R1’s pressure injury to this Department within seven (7) days of staff’s discovery. The investigation revealed that R1 was admitted to this facility on November 24, 2017, without wounds or pressure injuries per the resident’s log dated November 24, 2017. R1’s personal service plan developed on December 4, 2017 by the facility put an emphasis on assessing for skin changes and/or skin breakdown while providing bathroom assistance due to R1’s diagnoses. On December 25, 2017, R1 had a bowel accident while having dinner with family at the facility. Facility staff (S1) assisted R1 with shower and changing and observed a “small hole in the middle of R1’s buttocks” and blood in urine. S1 notified facility nurse (S2) about the blood in the urine and filled out a skin assessment sheet on December 25, 2017, but did not inform S2 or S1’s supervisor of the wound. S1 stated S1 did not notify S2 or S1 supervisor because S1 thought that R1 will be brought to the hospital due to the blood in R1’s urine. Continued, see LIC 809-C, page 2 of 3.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BROOKDALE SAN JOSE	FACILITY NUMBER: 435202447
	VISIT DATE: 05/18/2021

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

R1’s family was also not notified of the wound but was notified of the blood in R1's urine. R1 refused to go to the hospital on December 25, 2017 and family agreed that facility should monitor R1 and if a recurrence of blood in urine was observed, 9-1-1 should be called.

On December 26, 2017, at approximately 2:30 p.m., 9-1-1 was called for R1 due to a recurrence of blood in urine. R1 was admitted to a general acute care hospital on December 26, 2017, for symptoms unrelated to the wound. Hospital admission records revealed, however, that R1 had 3 pressure injuries – one unstageable, one stage 2 and one stage 1. On January 3, 2018, R1 was discharged to a skilled nursing facility and passed away on January 17, 2018 for a cause not related to R1’s injuries.

Based on observation and record review, the licensee did not assess R1’s skin condition when assisting R1 with toileting and showers. The licensee also did not report or seek treatment for R1’s skin conditions which developed into unstageable pressure injuries that required medical intervention.

At the time of the complaint visit on May 10, 2018, an immediate civil penalty of $500 was issued and the licensee was informed that the issuance of an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that an additional civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, May 18, 2021, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on May 10, 2018, the amount of the civil penalty issued is reduced to $9,500.

Continued, see LIC 809-C, page 3 of 3.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BROOKDALE SAN JOSE	FACILITY NUMBER: 435202447
	VISIT DATE: 05/18/2021

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	A copy of the LIC 421D was given to ED and originals were signed. Exit interview conducted. A copy of the report issued. Appeal Rights provided. Executive Director Marielouise Harris' signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3