435202447-5-11-2024-26-AS-RMAO-D5N2LN-20240526172949

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 05/10/2024
Date Signed: 05/11/2024 01:22:47 PM

Unfounded

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
07/22/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220722114741

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: 211	DATE:	05/10/2024
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Ashwini Sharma		TIME COMPLETED:	03:16 PM

ALLEGATION(S):

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Staff did not seek medical attention to resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Associate Executive DIrector (AED) Ashwini Sharma.

On 07/22/2022, the Department received a complaint with the allegation that facility staff did not seek medical attention to resident in care.

On 07/28/2022, the Department conducted an initial investigation visit.

LPA interviewed 3 staff and obtained resident Physician’s Report’s, Service Plan, Admission Orders, and Residency Agreement

Continue on LIC9099-C. Page 1 of 2.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

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 2

Control Number 26-AS-20220722114741

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: 05/10/2024

NARRATIVE

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Staff did not seek medical attention to resident in care:

The facility were alleged neglected on resident R1's thyroid condition.

On 07/28/2022, LPA interviewed 3 staff (S1 - S3). 3 out of 3 staff stated the facility staff provide good care and supervision to resident R1. S1 stated resident R1 already moved out from the facility on 12/31/2021. S1 stated he/she does not understand why the complaint coming out more than 7 months. S2 stated the facility arranges resident's doctor appointment if needed and provides transportation for resident's doctor appointment if needed.

A review of R1's physician reports dated on 05/12/2021 and 04/14/2020, the doctor prescribed the medications for R1's thyroid condition. A review of R1's Medication Administration Records dated from 09/01/2021 to 11/30/2021, R1's doctor prescribed medications for thyroid condition were administered every day as doctor orders. A review of R1's Personal Service Plans dated 05/12/2020, 06/18/2020, 01/21/2022, 09/08/2022, R1's thyroid condition were addressed in the service plans. The facility commented on that the facility is capable of providing many therapeutic diets to meet resident's special dietary needs. A review of the Residency Agreement, the transportation service is included.

Based on the interviews and documents reviewed, the facility provided care and supervision to resident R1. The facility administered the doctor prescribed medications to R1 as doctor's order. The facility addressed R1's health condition in R1's service plan. The facility is not medical service facility, so the medical treatment was not allowed to provide to residents by the facility.

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

Exit interview was conducted with AED. The report was provided to AED for signature. A copy of the report was provided to AED.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2