<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 10/03/2022
Date Signed: 10/03/2022 02:53:50 PM

Document Has Been Signed on 10/03/2022 02:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 JOSEFACILITY NUMBER:
435202447
ADMINISTRATOR:SHARON MONCKFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 153CENSUS: DATE:
10/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Anh "Audrey" BuiTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with Associate Executive Director (AED), Anh "Audrey" Bui. The purpose of the visit was to obtain additional information on incident reports the Department received regarding missed medications.

On 09/19/2022, the facility reported 26 residents in memory care who had missed their AM medications due to insufficient medtechs that morning and lack of communication. On 09/20/2022, the facility reported the incident to the Department, informed the resident's responsible parties, and resident's physician's of the missed medications. The facility staff monitored the resident's for 48 hours and no residents displayed adverse reactions due to the missed medication.

After the incident, the facility had provided training with the staff involved and hired multiple medtechs and nurses. Going forward, the facility had developed a plan in place if this incident were to happen in the future. On 09/26/2022, the facility had conducted an in-service training to all medtechs and nurses on the call-off policy and additional information relating to their job duties. AED will send LPA documentation of the training by 10/04/2022.

The following documents were obtained to include R1's physician's report and needs and services plan.

A deficiency was cited per California Code of Regulations, Title 22.

This report was reviewed with Audrey Bui and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/03/2022 02:53 PM - It Cannot Be Edited


Created By: Christine Dolores On 10/03/2022 at 02:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BROOKDALE SAN JOSE
FACILITY NUMBER: 435202447

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2022
Section Cited
CCR
87705(c)(4)

1
2
3
4
5
6
7
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee had corrected the deficiency prior to visit by providing in-service training to all medtechs and nurses, hiring additional medtechs and nurses, and developing a plan in place if this incident were to happen in the future.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not ensure there was enough medtechs/nurses the morning of 09/19/22 to support each residents health care needs resulting to 26 memory care residents missing their AM medications, which poses an immediate health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2