435202447-11-8-2022-26-AS-SYIP-CLLTXV-20221128140744

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 11/08/2022
Date Signed: 11/08/2022 10:50:52 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
06/28/2022 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20220628144556

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:	DATE:	11/08/2022
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Audrey Bui		TIME COMPLETED:	10:51 AM

ALLEGATION(S):

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Resident sustained a fracture while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced visit to deliver the complaint investigation findings regarding the above allegation. LPA met with facility Associate Executive Director Audrey Bui (Admin).

The Deprtment opened the investigation on 06/29/2022. During the course of the investigation, The Department interviewed 4 facility staff members, facility staff were unable to identify the origin of R1's injury. Review of R1's medical records and interviews with hospice and hospital staff did not indicate any suggestion that R1's injuries were caused intentionally. The Department interviewed 3 residents, 2 out of 3 residents interviewed indicated that they were comfortable at the facility, and that staff had never injured them or made them uncomfortable. The remaining interviewed resident was unable to answer the question.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

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-20220628144556

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BROOKDALE SAN JOSE	FACILITY NUMBER: 435202447
	VISIT DATE: 11/08/2022

NARRATIVE

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Review of resident medical records noted to be consistent with narrative provided by both the facility and hospice staff. Interviews with R1's responsible party and hospice staff indicated that the injury likely stemmed from R1's pre-diagnosed medical conditions. The Department attempted to interview and obtain medical records from R1's surgeon, but at this point medical records have not been submitted and R1's surgeon is unable to have been contacted. This report will be amended in the event that contact is made with R1's surgeon if such contact substantively changes the conclusions of this investigation.

The department has investigated the above allegation. Based on records reviewed and interviews conducted, 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.

No citations noted during today's inspection. Exit interview was conducted with Associate Executive Director Audrey Bui and a copy of this report was provided for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

LIC9099 (FAS) - (06/04)

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