435202447-10-13-2021-26-AS-KHOS-C88KBJ-20211028074538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 10/12/2021
Date Signed: 10/13/2021 01:30:41 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
05/13/2020 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200513123756

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: 68	DATE:	10/12/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Marie Harris		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff did not respond to residents alerts in a timely manner
Staff failed to properly assist resident while toileting

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted a subsequent unannounced investigation visit to deliver the complaint findings. LPA met with the Executive Director Marie Harris.

On 05/19/2020, LPA Maria Kamara conducted an unannounced initial tele-investigation visit. LPA interviewed 2 residents and 7 staff.

On 08/10/2021, LPA Ng conducted an unannounced subsequent investigation visit. LPA interviewed 3 additional residents and 3 additional staff.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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-20200513123756

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: 10/12/2021

NARRATIVE

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Regarding allegation “staff did not respond to residents alerts in a timely manner,” 4 out of 5 residents denied staff not responding to residents’ alerts in a timely manner. 10 out of 10 staff denied not responding to residents’ alerts in a timely manner. 10 out of 10 staff also denied seeing other staff not responding to residents’ alerts in a timely manner.

Regarding allegation “facility staff did not meet resident's toileting needs in a timely manner,” 4 out of 5 residents denied staff not meeting resident's toileting needs in a timely manner. 10 out of 10 staff denied not meeting residents’ toileting needs in a timely manner. 10 out of 10 staff also denied seeing other staff not meeting residents’ toileting needs in a timely manner.

Based on record review, the pendant response log revealed that there was no over an hour response time as alleged.

Between 02/14/2020 and 05/19/2020, the Department investigated an unrelated complaint that was similar to this complaint’s allegations. LPAs Gladys Kuizon and Jackie Jin interviewed 12 residents and 13 staff.

12 out of 12 residents stated their calls were being responded and their needs were being met. 13 out of 13 staff stated that staff responded to residents' calls and they believed that all the residents' needs were being met by staff.

Based on interviews and record review, the Department has determined that the allegations were UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

This report was reviewed with Executive Director and a copy of this report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC9099 (FAS) - (06/04)

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