435202447-9-11-2020-26-AS-RMAO-BTNRSX-20200921131725

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 09/11/2020
Date Signed: 09/11/2020 02:50:44 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
12/18/2019 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20191218123414

FACILITY NAME:	BROOKDALE SAN JOSE		FACILITY NUMBER:	435202447
ADMINISTRATOR:	MICHELE MERRITT		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	153	CENSUS: 125	DATE:	09/11/2020
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Antonette Edwards		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff does not get residents out of bed.
Staff does not take residents to breakfast.
Staff does not empty residents catheter bags.
Staff does not provide a safe environment for resident.
Staff does not provide residents medication timely.
Staff does not brush residents teeth.
Staff does not get residents dressed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gladys Kuizon conducted a subsequent complaint tele-visit today to deliver investigation findings. Due to COVID-19 preventive measures, facility visits have been suspended. LPA met with Assisted Living Director (ALD) Antonette Edwards.

On December 18, 2019, the Department received the above allegations against this facility. Reporting party (RP) alleged that facility staff is neglecting care for multiple residents.

On December 30, 2019, LPA Elizabeth Larios conducted an unannounced initial complaint investigation visit and conducted staff and resident interviews. Resident and staff interviews were conducted between December 30, 2019 to August 26, 2020.

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: 09/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2020

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20191218123414

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: 09/11/2020

NARRATIVE

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LPA reached out to 12 residents. 10 out of 12 residents responded and were interviewed. 10 out of 10 residents stated that staff assists them with their needs and stated that they feel safe in the facility. 8 out of 10 residents does not need assistance getting in and out bed and is able to go to the dining room independently for meals. 2 out of 10 residents stated that they need assistance ambulating and staff always assisting them when needed, including putting on clothes and showering. 10 out of 10 residents stated they are able to brush their own teeth.

LPA reached out to 10 random staff members for interviews. 9 staff responded and were interviewed. 9 out of 9 stated that they have not observed any resident not being assisted with getting in and out of bed, going to breakfast, and grooming. All staff stated, however, that they respect a resident's right to refuse assistance and a resident may choose to eat in their room and not change clothes.

6 Resident Care Associates (RCA) were interviewed and stated that they have not observed any catheter bags not being emptied. 5 RCAs confirmed that they have personally emptied residents' catheter bags.

3 Medications Technicians (MT) were interviewed. 2 out of 3 MTs stated that they are always on time with medications administration.

The investigation included a review of facility records including residents' care plans, medications administration records, and staff schedule.

The Department has investigated the above allegation. Based on interviews conducted and records reviewed the Department found that the above allegation is 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 and a copy provided to ALD Antonette Edwards by email.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2020

LIC9099 (FAS) - (06/04)

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