435202447-6-7-2021-26-AS-KHOS-C3TNGP-20210609102728

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 06/07/2021
Date Signed: 06/07/2021 03:17:12 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
02/08/2021 and conducted by Evaluator Ryker Heberle

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210208130525

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: 82	DATE:	06/07/2021
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Rizaldy Carreon		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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1. Facility mismanages residents' medications.
2. Unqualified staff dispenses residents' medications.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryker Heberle and Licensing Program Manager (LPM) Gladys Kuizon conducted a complaint tele-visit today to deliver investigation findings and met with Assisted Living Director (ALD) Rizaldy Carreon.

On February 8, 2021, the Department received a complaint against the facility alleging that the facility allows unqualified staff to dispense and administer medications. Consequently, residents' medications are mismanaged and not administered per physician's orders.

An initial complaint investigation was conducted on February 9, 2021. Facility records were requested and reviewed. On February 23, 2021, the Department received a written incident report from the facility stating medication errors were identified through an internal audit conducted by Executive Director (ED) Marie Harris and Health & Wellness Director (HWD) Harriette Vega.

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

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021

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 3

Control Number 26-AS-20210208130525

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: 06/07/2021

NARRATIVE

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Based on the written incident report (LIC 624), injectable medication for 3 residents (R1-R3) were administered by staff not qualified to administer injections from December 2020 to January 2021. According to report, residents' physicians and responsible parties were informed. Facility also conducted staff training.

Staff interviews were conducted. 4 of 4 resident care associates (RCA) who were interviewed stated they do not pass or administer medications because they have not received the training. They stated that only Medications Technicians (MT) and nurses assist with medications.

5 of 5 staff MTs/nurses who were interviewed stated they have completed medications training as required. 4 of 5 MTs/nurses interviewed stated they have caught medication administration errors by their co-worker on more than one occasion, including missed doses and medications not being ordered prior to medication supply running out.

On May 18, 2021, the Department conducted an audit of the facility's Assisted Living medication cart. Discrepancies between medication administration record and actual available medication were identified in 6 out of 7 residents' medication records that were reviewed. No hospitalization or resident refusal were indicated to account for discrepancy. During review, a facility staff reported finding a cup of medications at approximately 2:30 PM by resident (R1)'s bedside. Staff stated it is not clear whether this is morning or noon medication.

Staff training records were reviewed and revealed that staff MTs received required medications training. However, staff MTs (S1-S2) who administered insulin injections to residents from December 2020 to January 2021 were not appropriately skilled professionals qualified by law to administer injections. During interview, ED confirmed S1-S3 were not appropriately licensed to administer injections.

The Department has conducted an investigation of the above allegations. Based on LPAs’ observations, records reviewed and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D. Appeal rights provided. Exit interview conducted with Executive Director Marie Harris.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20210208130525

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: 06/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/08/2021 Section Cited CCR 87629(b)(1)	1 2 3 4 5 6 7	87629 INJECTIONS. (b) ...licensees who admit or retain residents who require injections shall be responsible for the following:(1)Ensuring that injections are administered by an appropriately skilled professional...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit a written plan of action to CCLD by POC due date.
	8 9 10 11 12 13 14	Based on written records and staff interviews conducted, staff MedTechs who were not licensed skilled professionals permitted to administer injections provided insulin injections to residents. This posed an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
Type A 06/08/2021 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 INCIDENTAL MEDICAL AND DENTAL CARE. (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit a written plan of action to CCLD by POC due date.
	8 9 10 11 12 13 14	Based on medication audit conducted on 05/18/21, 6 of 7 resident medication records contained discrepancies such as extra medications in relation to recorded start date of administration. This poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14

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 Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021

LIC9099 (FAS) - (06/04)

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