435202447-7-29-2021-26-AS-KHOS-C68NDH-20210825102221

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 07/29/2021
Date Signed: 07/29/2021 05:13:15 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
06/30/2021 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210630151909

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: 80	DATE:	07/29/2021
		UNANNOUNCED	TIME BEGAN:	10:23 AM
MET WITH:	Hariette Vega		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff does not assist resident with feeding.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gladys Kuizon conducted a complaint visit today to deliver investigation findings. LPA met with Health and Wellness Director (HWD) Harriette Vega.

On 06/30/2021, the Department received a report alleging that facility staff refuse to assist resident (R1) who is unable to feed without assistance.

On 07/09/2021, an unannounced initial complaint investigation visit was conducted. Interviews of staff and resident were conducted.

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: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

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-20210630151909

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: 07/29/2021

NARRATIVE

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The investigation revealed that R1 is under hospice care since 02/28/2021. R1's hospice care plan was reviewed. On 07/02/2021, visiting hospice nurse (H1) documented that R1 is getting weaker, has difficulty feeding self, has not been getting up for meals, has decreased appetite, taking only 20% of meals, and only eats once a day. H1 also noted that a private caregiver may be needed when R1 can't feed self anymore.

On 07/09/2021, R1 was interviewed. R1 stated that R1 has no trouble feeding at this time and R1 will ask for help if R1 needs assistance. R1 stated staff has been responsive and nobody has refused to help R1. R1 demonstrated knowledge of activating R1's pendant alarm. On 07/29/2021, an unannounced facility visit was conducted and R1 stated R1 is able to feed self and demonstrated ability to activate pendant alert at 10:48 AM. Staff responded at 10:52 AM. R1 stated R1 had breakfast already.

Staff were interviewed. 4 out of 4 staff who were interviewed stated there is no facility policy regarding not assisting hospice residents with feeding. 2 out of 4 staff who were interviewed stated they have personally assisted R1 with feeding. 3 out of 4 staff stated R1 is still able to feed self, but very slowly. Staff stated R1 may not be able to feed self in the future and the care plan will be updated accordingly.

On 07/09/2021, Executive Director (ED) stated that the facility has a policy that assistance with feeding is done in the residents' private apartments only. Assistance with feeding is not allowed in the communal dining room to protect residents' dignity and residents and family members understand the policy. ED stated that if a resident needs assistance with feeding, room service will be provided.

LPA attempted to reach R1's responsible party on 07/01/2021, 07/09/2021, and 07/28/2021 but was unable to receive a response.

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 HWD. 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: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC9099 (FAS) - (06/04)

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