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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202583
Report Date: 05/26/2023
Date Signed: 05/26/2023 05:03:09 PM

Substantiated


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
06/15/2021 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20210615091611
FACILITY NAME:JESSIE COURT CARE HOMEFACILITY NUMBER:
435202583
ADMINISTRATOR:VU, KRISTINE ABLAOFACILITY TYPE:
740
ADDRESS:2934 JESSIE COURTTELEPHONE:
(408) 628-4702
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 5DATE:
05/26/2023
UNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Kristine VuTIME COMPLETED:
11:33 AM
ALLEGATION(S):
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Resident sustained injuries from a fall while in care.
Staff did not seek timely medical attention for a resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted a complaint visit to deliver investigation findings. LPA met with Administrator (ADM) Kristine Vu.

On 06/15/2021, the Department received a complaint about the above allegations. A complaint investigation visit was conducted on 06/23/2021. Three staff, three residents and ADM were interviewed.

Resident's physician report, Appraisal Needs and Service Plan, and incident reports were obtained.

Continued, see LIC 9099-C, page 1 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
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 4
Control Number 26-AS-20210615091611
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: JESSIE COURT CARE HOME
FACILITY NUMBER: 435202583
VISIT DATE: 05/26/2023
NARRATIVE
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Resident sustained injuries from a fall while in care.
Staff did not seek timely medical attention for a resident while in care.

On 06/23/2021, LPA interviewed staff (S1), S1 stated that on 5/14/2021, at around 3:00AM, staff (S2) heard a noise from R1’s bedroom. S2 found R1 on the floor wherein R2 was assess and first aid was applied.

S1 stated that R1 was provided with a call bell pendant to use when he/she needs assistance from staff. S1 stated that R1 did not use call bell pendant to call for help or assistance. S1 stated that S2 was generally good at evaluating residents when to call an ambulance and when to call family particularly at midnight.

On 09/23/2021, LPA interviewed staff (S3), S3 stated that on 05/14/2021, around 3:00AM, S3 heard a noise coming from R1’s bedroom and subsequently heard R1’s yelling for help. S3 stated he/she found R1 on the floor wherein R1 was assessed for injuries and applied first aid. S3 stated that R1 got up from bed to use restroom when he/she hit a chair in his/her bedroom causing him/her to fall on the ground.

S3 stated that R1 was assisted back to bed after S3 assessed R1. S3 did not think it was urgent to send R1 to the hospital or call 911 because R1 stated he/she was alright. At 6:30AM on 5/14/2021, R1 informed S3 that he/she needed to see a medical doctor instead S3 called R1’s family member who arrived at the facility at 7:00AM. R1’s family observed R1’s right eye severely swollen and bleeding. R1 was immediately taken to the hospital Emergency Room by his/her family member.

On 5/14/2021, the Department received an incident report LIC624) submitted by the facility wherein it stated that R1 slid off the bed where staff found R1 on the floor at 3:00AM. Staff noted R1’s right eye was swollen wherein a cold compress was applied. R1’s responsible party was notified of the events and R1 was taken to the emergency hospital at 8:00AM.

Based on R1’s recent Physician’s report of 05/05/2021, R1 was non-ambulatory and diagnosed with Mild Cognitive Impairment (MCI) wherein R1 was unable to communicate needs and had visual impairment. R1 was unable to independently transfer to and from bed, and unable to leave facility unassisted due to at risk of fall.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20210615091611
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: JESSIE COURT CARE HOME
FACILITY NUMBER: 435202583
VISIT DATE: 05/26/2023
NARRATIVE
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A review of R1’s Appraisal, Need and Services Plan dated 3/18/2021, according to care plan, R1 was ambulatory and perform ADLs but needs assistance during bathing which contradicts to R1’s physician’s report (5/5/21), R1 was non-ambulatory and was not able to self-bath due to his/her physical and mental condition. R1’s Appraisal, Need and Services Plan (LIC625) was not updated to address R1 being at risk of fall.

Based on information gathered during investigation, R1’s responsible party (RP) was called by facility staff to take R1 to the hospital around 7:00AM on 05/14/2021. When RP arrived at the facility, R1’s right eye was observed severely swollen and bleeding.

Staff did not call RP earlier because staff did not want to wake RP’s up and because R1’s eye did not become swollen right after the fall. By the time RP arrived at the facility, R1’s eye was already swollen and bleeding. Facility staff did not call R1’s Primary Care Physician or called an ambulance to the nearest emergency hospital to be seen.

A review of the facility’s program plan under ‘Emergencies’ (page 10 of 17) states, “…For Health emergencies, facility policy is to call 911…” Under ‘House Rules” (page 1 of 6) states, “For health emergencies, our policy is to call 911..”

Based on investigation through interviews and records reviews, R1 had neurocognitive disorder (MCI) who had a fall resulted to an eye injury. According to R1’s physician’s report, R1 was not able to communicate needs although staff stated that Staff did not conduct a welfare check on R1 after his/her fall at 3:00AM not until 7:00AM. Staff did not seek timely medical assistance for R1 instead staff called R1’s responsible party who took R1 to emergency hospital. The preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D. Appeal Rights were attached.



Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report D was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20210615091611
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: JESSIE COURT CARE HOME
FACILITY NUMBER: 435202583
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/27/2023
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health.

This requirement was not met by:
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Administrator agreed to submit Plan of Correction by the POC due date to CCL office.
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Based on interviews and records review, on 5/14/2021, staff did not seek timely medical services to resident who obtained severe injuries in the facility. This posed an immediate risk to the health, safety of the resident in care.
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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: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4