435202737-7-9-2024-26-AS-KHOS-D85PLW-20240814112526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202737
Report Date: 07/08/2024
Date Signed: 07/09/2024 09:13:05 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/07/2021 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210607145905

FACILITY NAME:	OAKMONT OF SAN JOSE		FACILITY NUMBER:	435202737
ADMINISTRATOR:	HIGGINS, JOLIE		FACILITY TYPE:	740
ADDRESS:	917 THORNTON WAY		TELEPHONE:	(408) 371-7100
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	0	CENSUS: 0	DATE:	07/08/2024
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Francisco Sudiacal		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Facility is not providing resident's records to authorized representative.
Facility is not maintaining resident records for three years.

INVESTIGATION FINDINGS:

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On 7/8/2024, Licensing Program Analysts (LPAs) Grace Donato & Christine Dolores conducted an unannounced complaint investigation visit. LPAs met with Business Office Director, Francisco Sudiacal and LPAs explained the purpose of today's visit.

Regarding the allegation of Facility is not providing resident's records to authorized representative & Facility is not maintaining resident records for three years, RP stated that a request was made for Caregivers Task Sheets and the Evaluation Assessment Point System from the facility, but was not provided.

Based on the information provided by the RP, the Evaluation Assessment Point System was provided by the facility on a later date of November 20, 2020. However the Caregiver Task Sheets were not given.

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

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-20210607145905

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: OAKMONT OF SAN JOSE	FACILITY NUMBER: 435202737
	VISIT DATE: 07/08/2024

NARRATIVE

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The purpose of these forms is to provide direction, instruction and guidance for the care staff in terms of the care being provided to each residents. This is not part or the residents record that is maintained in the facility.

LPA Donovan interviewed the Executive Director (ED), the facility's policy on records retention stated clearly that the staffing work sheet is to be destroyed at the end of the month.

According to Title 22 regulations, 87506(b) Resident Records, the Caregivers Task Lists is not part of the records that the facility is required to keep.

LPA Donovan also observed that the facility has a storage area and noted resident files boxes with dates from 2016 forward.

Based on interviews, records review and observations, the department has determined that these allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

Report is reviewed and copy is provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

LIC9099 (FAS) - (06/04)

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