435202447-3-1-2021-26-AS-KHOS-BYYQB9-20210310110110

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 02/26/2021
Date Signed: 03/01/2021 10:18:35 AM

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
02/18/2021 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210218085745

FACILITY NAME:	BROOKDALE SAN JOSE		FACILITY NUMBER:	435202447
ADMINISTRATOR:	ODETTE COLONDRES TORRES		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	153	CENSUS:	DATE:	02/26/2021
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Rizaldy Carreon, Assisted Living Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff spoke inappropriately to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gladys Kuizon conducted a complaint investigation tele-visit today to deliver investigation findings. LPA met with Assisted Living Director Rizaldy Carreon via video conferencing. Due to COVID-19 restrictions, facility visits have been suspended.

On February 18, 2021, the Department received the above allegation against the facility for an incident that occurred on October 18, 2020 and directly related to Complaint # 26-AS-20201028152039.

Resident and staff interviews were conducted. 7 out of 8 staff stated that they have not witnessed any co-worker being verbally abusive to resident (R1) or any resident.

Continued, see LIC 9099-C, page 2 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021

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-20210218085745

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: 02/26/2021

NARRATIVE

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The investigation revealed that on October 18, 2020, staff (S1) witnessed staff (S2) cursing at R1 while S1 and S2 were transferring R1 to bed. S1 stated that S2 cursed in Tagalog and S1 understood it but R1 did not. S1 stated the incident occurred in R1's private room and there were no other witnesses. There were no cameras in the facility's private areas.

S1 reported the incident to staff, S3, who was off that day. On October 21, 2020, upon S3's return to work, S3 reported the incident to facility management and an investigation was conducted by the facility's human resource (HR) department. S2 was suspended from work while the investigation was on-going, however, S2 resigned from work prior to the conclusion of the investigation. LPA was unable to reach S2 for an interview.

R1's medical records were reviewed. Per R1's diagnoses, R1 has memory impairment and is not a good historian. R1 is also non-verbal. On February 11, 2021, LPA attempted to interview R1. R1 did not respond. LPA observed R1 awake, slightly reclined to a seated position in bed, and with no visible signs of injury on exposed skin. R1's clothes and bed linens were observed clean and in good repair.

On February 11, 2021, LPA attempted to interview residents in the facility's Memory Care unit where R1 resides. 5 out of 5 residents were unable to respond to interview questions due to cognitive impairment. R1 does not have a room mate.

San Jose Police Department (SJPD) report #20-295-9514 was obtained and reviewed.

The Department has investigated the above allegations. Based on interviews conducted and records reviewed, the Department found that the above allegations are 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.

Exit interview conducted and a copy of this report was provided electronically for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021

LIC9099 (FAS) - (06/04)

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