435202447-6-28-2021-26-AS-SYIP-C4UVF5-20210712162322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 06/25/2021
Date Signed: 06/28/2021 10:52:57 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
04/06/2021 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210406163956

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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Facility staff made a sexually inappropriate hand gesture towards resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gladys Kuizon conducted a subsequent complaint investigation visit today to deliver investigation findings. LPA met with Executive Director (ED) Marie Harris.

On April 6, 2021, the Department received a complaint report alleging that a facility staff (S1) made a sexually inappropriate hand gesture to a resident (R1). The Department conducted an initial complaint investigation visit on April 7, 2021.

On April 22, 2021, interviews were conducted. R1 stated that R1 likes some caregivers better than others but R1 cannot recall the names of the caregivers. R1 stated that one caregiver made R1 uncomfortable during a shower assist but confirmed that the caregiver did not touch R1 inappropriately. According to R1, the caregiver made a hand gesture that is "like jacking off."

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)

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Control Number 26-AS-20210406163956

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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R1 was unable to identify the caregiver and stated R1 may have interpreted the gesture wrong.

The Department was unable to contact staff, S1, after multiple attempts by phone and mail. S1 was placed on administrative leave by the facility upon receipt of the complaint and voluntarily resigned from the facility shortly after.

Resident, R2, who was also assisted by S1 during showers, was interviewed. R2 stated S1 had not made any inappropriate gestures towards R2 and that S1 was respectful and polite.

Executive Director (ED) was interviewed. ED stated there had been no previous complaints from residents or staff against S1.

On April 27, 2021, San Jose Police Department Report (SJPD) regarding this incident was obtained and reviewed. Based on SJPD report, on March 29, 2021, R1 was interviewed and stated S1 made what R1 interpreted as masturbating hand gestures. R1 stated R1 may be mistaken as R1 is unfamiliar with today's gestures. R1 confirmed there was no physical contact involved.

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.

Exit interview conducted with ED, 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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