435202447-9-30-2021-26-AS-RMAO-C7PLL6-20211011085035

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 09/30/2021
Date Signed: 09/30/2021 01:17:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2020 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20200610165259

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: 67	DATE:	09/30/2021
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Marielouise Harris		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident suffered from a fall resulting in fractures

INVESTIGATION FINDINGS:

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LPAs Marybeth Donovan and Christine Dolores arrived unannouced to deliver the complaint investigation findings of the above allegation and met with Marielouise Harris Executive Director.

On 6/10/2020, the Department received notification of the above complaint allegation.

On 06/12/2020, the Department conducted an initial 10 day complaint investigation of the above allegation wherein LPA Donovan obtained staff rosters; four resident records to include in part emergency contact information, physician's report, assessments, appraisal needs and services plan and progress notes, incident reports, and contact information.

Between 6/15/2020 and 11/30/2020 interviews were conducted with 7 staff (S1-S7), 2 medical professionals (M1 and M2), 1 witness (W1), 1 family member (F1), and 3 residents (R1-R3). Between 6/29/2020 and 12/2/2020 records reviewed included medical assessments, physician orders, hospital discharge records and home health agency progress notes.
Page 1 of 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

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 4

Control Number 26-AS-20200610165259

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BROOKDALE SAN JOSE	FACILITY NUMBER: 435202447
	VISIT DATE: 09/30/2021

NARRATIVE

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Based on interviews with staff, medical professionals and residents, they could not prevent R1's fall. R1 was placed in common areas for greater observation. R1 was placed in the hallway and in the living room so that R1 may be monitored more closely. Although R1 was a fall risk, according to Title 22, Personal Rights, the facility may not restrain a resident to prevent falls from a bed or chair. Facility does not have the capability to provide one on one care in order to prevent falls.

The Department has investigated the above allegation. Based on interviews 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.

LPAs review this report with Marie Louise Harris Executive Director and a copy provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2020 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20200610165259

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: 67	DATE:	09/30/2021
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Marielouise Harris		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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5
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9

Resident sustained unexplained injuries while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

LPAs Marybeth Donovan and Christine Dolores arrived unannouced to deliver the complaint investigation findings of the above allegation and met with Marielouise Harris Executive Director.

On 6/10/2020, the Department received notification of the above complaint allegation.

On 06/12/2020, the Department conducted an initial 10 day complaint investigation of the above allegation wherein LPA Donovan obtained staff rosters; four resident records to include in part emergency contact information, physician's report, assessments, appraisal needs and services plan and progress notes, incident reports, and contact information.

Between 6/15/2020 and 11/30/2020 interviews were conducted with 7 staff, 2 medical professionals, 1 witness, 1 family member, and 3 residents. Between 6/29/2020 and 12/2/2020 records reviewed included medical assessments, physician orders, hospital discharge records and home health agency progress notes.
Page 1 of 2

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20200610165259

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BROOKDALE SAN JOSE	FACILITY NUMBER: 435202447
	VISIT DATE: 09/30/2021

NARRATIVE

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Based on interviews with medical staff, R1's older bruises, which were at varies stages, were not painful at the time of R1's hospital examination on 06/09/2020 and did not indicate there were underlying injuries where old bruising was located. Medical records and interviews with medical professional and R1's responsible party confirmed that R1 bruises easily due to being on blood thinning medication. Interviews with staff also revealed that they were diligent in reporting R1's had a fall to medical professionals.

This Department has investigated this allegation. Based on interviews conducted, records reviewed, the Department has found that this allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

Report review with Marielouise Harris Executive Director and a copy provided.

Page 2 of 2

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4