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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202772
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:29:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
03/07/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20230307100804
FACILITY NAME:OAKMONT OF SILVER CREEKFACILITY NUMBER:
435202772
ADMINISTRATOR:BAGHERI, TAYEBEHFACILITY TYPE:
740
ADDRESS:3544 SAN FELIPE ROADTELEPHONE:
(669) 288-5000
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:0CENSUS: 57DATE:
09/18/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Abby CastilloTIME COMPLETED:
04:26 PM
ALLEGATION(S):
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Facility fails to prevent resident from leaving facility without supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Resident Care Coordinator (RCC) Abby Castillo.

On 3/7/2023, the Department received a complaint with the allegation that the facility fails to prevent resident from leaving facility without supervision.

On 3/17/2023, the Department conducted an initial investigation visit. LPA interviewed 3 staff and 1 residents.

LPA toured the facility and residents rooms. LPA requested resident physician reports, appraisal needs and service plan, incident reports and admission agreement.

Continue on LIC9099-C. Page 1 of 3.



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
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-20230307100804
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202772
VISIT DATE: 09/18/2024
NARRATIVE
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Facility fails to prevent resident from leaving facility without supervision:

On 3/17/2023, LPA interviewed Regional Operation Specialist (S1). S1 stated R1 moved in the facility in September 2022. S1 stated R1 was initially admitted at the Assisted Living unit. R1 eloped from the facility on 9/30/2022 and then the facility moved R1 to Memory Care Unit. R1 eloped from the facility on 10/25/2022. On 2/22/2023, R1 eloped from the facility again and the facility moved R1 to another room of memory Care unit.

LPA interviewed Business Office Director (S2). S2 stated resident R1 has 3 elopement incidents. S2 stated after R1's elopement incidents, the facility did some actions. S2 stated the facility moved R1 from Assisted Living Unit to Memory Care Unit which provides more care and supervision. The facility moved R1 to another Memory Care unit room, the outside of the room is the backyard garden with fence surrounded. The facility suggested a 1:1 care for R1. But R1's family did not agree with it. S2 stated the facility enforced R1's visitors to sign in and sign out when taking R1 out.

LPA interviewed a facility nurse (S3). S3 stated the facility requested R1 to wear wander guard, but R1 refused. S3 stated the facility talked to R1's doctor and changed R1's medications. S3 stated the facility requested R1 to have 1:1 care, but R1's family refused. S3 stated the facility suggested R1 to have family accompanied for 72 hours and 1:1 care for 3 weeks for R1 to be stable.

LPA interviewed resident R1. R1 stated the facility food is good and the environment is good. R1 admitted he/she eloped from the facility several times. R1 stated he/she just needs more activities and more free time.
Based on reviews of the incident reports the facility sent to CCL office, R1 did have elopement incidents on 9/30/2022, 10/25/2022, and 2/22/2023.



Continue On LIC9099-C, Page 2 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 26-AS-20230307100804
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202772
VISIT DATE: 09/18/2024
NARRATIVE
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On 9/30/2022, around 3 :00PM, R1 was found not in the facility. R1's family was visiting R1 and was able to reach R1 via R1's cell phone. R1 was picked up and returned to the facility.

On 10/25/2022, around 10:30PM, R1 was found not in the facility. On 10/26/2022, around 12:30AM, R1 was found at family member's house. On 10/26/22, around 2:00AM, R1 was brought back to the facility by family member.

On 2/22/2023, around 7:00PM, R1 was found not in the facility. R1's room window was found wide opened and the screen window was found pushed out. R1 was brought to R1's POA's house. R1's POA brought R1 back to the facility.

Based on review of R1's physician report dated 8/19/2022, R1 has neurocognitive impairment and should be accompanied with staff when leaving the facility. R1 left the facility on 9/30/2022, 10/25/2022, and 2/22/2023 without the accompanies of the facility staff.

The Department has investigated the above allegation. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Citations were noted today. Please see LIC9099-D. Exit interview was conducted with RCC. A copy of the report was provide to RCC.

Page 3 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20230307100804
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202772
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2024
Section Cited
CCR
87464(f)(1)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by
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Administrator stated to submit a plan of correction by the POC due date to provide the training to staff to provide care and supervision to meet residents' needs and to provide the staff training log.
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Based on interview and record review, resident R1 had eloped from the facility with no supervision on 3 occasions which poses/posed an immediate Health, Safety, or Personal Rights risk to persons 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.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4