435202447-6-29-2021-26-AS-KHOS-C4PPCC-20210707111142

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 06/25/2021
Date Signed: 06/29/2021 09:14:32 AM

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
03/30/2021 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210330160704

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: 79	DATE:	06/25/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Marie Harris		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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1. Facility staffing is insufficient to meet resident's needs.
2. Facility did not follow resident's care plan.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gladys Kuizon conducted an unannounced complaint visit today and met with Executive Director Marie Harris to deliver investigation findings.

On March 30, 2021, the Department received a complaint against the facility alleging that the facility did not meet resident (R1)'s needs due to insufficient staffing. Furthermore, it was alleged that R1's care plan was not followed specifically when it comes to housekeeping and shower preferences.

On April 7, 2021, an initial complaint investigation visit was conducted. Records were requested and reviewed.

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: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

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 2

Control Number 26-AS-20210330160704

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: 06/25/2021

NARRATIVE

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Records revealed that R1 resided at this facility from April 2019 to February 2020. R1's Residency Agreement (RA) showed that basic services were agreed upon. No additional services were indicated. Per RA, basic services include staffing 24 hours a day/7 days a week and light housekeeping service once a week.

Resident and staff interviews regarding staffing and services provided at the facility and conducted around the time R1 resided at the facility were reviewed. 15 out 19 residents stated that staff is sufficient, responsive, and meets their needs. 4 out of 19 residents stated that staff response times varies and can be as long as over 30 minutes and they believe additional staffing is needed at the facility. All residents that were interviewed have no complaints about housekeeping and facility cleanliness. 11 out of 12 staff who were interviewed stated that they are able to meet their residents' needs in a timely manner and caregivers work together to check on all residents. 1 out of 12 staff stated there is a need for additional caregivers in assisted living.

On June 23, 2021, Assisted Living Director (ALD) was interviewed. ALD stated that residents' shower schedule are based on resident's preference. The facility did not have a shower log for 2019. ALD stated residents are not forced to take showers if they refuse or choose to wait until their preferred caregiver is available.

Facility staff schedule from August 2019 to February 2020 in the Assisted Living unit was reviewed. Staff schedule showed at least 4-6 staff consisting of caregivers, medications technician (MT), and licensed nurse scheduled in the morning and afternoon shift. In the graveyard shift, at least 2 caregivers and 1 licensed nurse or MT is scheduled.

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.

Exit interview conducted with Executive Director Marie Harris. A copy of this report was provided during visit.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC9099 (FAS) - (06/04)

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