435202447-2-26-2021-26-AS-KHOS-BYYQE6-20210310110548

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 02/26/2021
Date Signed: 02/26/2021 08:45:01 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
02/24/2021 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210224161555

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: 69	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 posts residents' confidential information in a public area.

INVESTIGATION FINDINGS:

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

At 1:43 PM, LPA conducted a virtual tour of the facility with ALD. The nurses' station and medications room in the first floor of the Assisted Living building was inspected. Staff members were observed by the nurses' station. No confidential information was observed posted in the area. LPA did not observe any visitors in the facility during inspection.

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

Substantiated

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)

Page: 1 of 3

Control Number 26-AS-20210224161555

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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LPA interviewed ALD regarding a report with accompanying photo evidence received by the Department that the facility posts residents' confidential information, including protected health information, in a public area. According to ALD, there was a resident roster poster that ALD put up in the first floor nurses' station while ALD was planning staff schedule and resident groupings a couple of days ago. ALD stated that the poster was unintentionally left there overnight and was taken down and moved to ALD's office afterwards.

ALD showed LPA the poster. LPA observed the following information on the poster: resident's first and last name, admission agreement date, move-in date, resident ID (date), unit #, assessment type which all indicated "AL", assessment date, and a medications column that contained either a "-", "B", or "C". There was no corresponding legend to translate the letter codes.

Based on LPA's review, no health information was identifiable from the poster. During inspection, the poster was observed kept in the ALD's office with closed, lockable doors and limited access.

Per Title 22 regulations, a register of current residents shall be treated as confidential.

The Department has conducted an investigation of the above allegation. Based on LPAs’ observations, records and photos reviewed and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

A deficiency is cited. See LIC 809-D. Appeal rights provided. A copy of this report was provided to ALD and Executive Director 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)

Page: 2 of 3

Control Number 26-AS-20210224161555

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/26/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/05/2021 Section Cited CCR 87508(c)(1)	1 2 3 4 5 6 7	87508 REGISTER OF RESIDENTS (c)(1) The register shall be treated as confidential information pursuant to Section 87506(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	OBSERVED CORRECTED DURING VISIT.
	8 9 10 11 12 13 14	Based on photo evidence received, interview with ALD, and LPA's observation, a wall poster containing names of current residents was posted in the first floor nurses' station wall accessible to non-staff members. This posed a potential risk to the personal rights of residents 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	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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3