435202779-12-6-2021-26-AS-RMAO-C9HMH2-20211208083644

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202779
Report Date: 11/10/2021
Date Signed: 12/06/2021 03:43:56 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
03/22/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20210322110613

FACILITY NAME:	REAL ELDERLY CARE		FACILITY NUMBER:	435202779
ADMINISTRATOR:	REAL, JOCELYN		FACILITY TYPE:	740
ADDRESS:	4858 POSTON DRIVE		TELEPHONE:	(408) 440-2441
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	6	CENSUS: 6	DATE:	11/10/2021
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Jocelyn Real, ADM		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff member is not qualified in taking care of residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint investigation to deliver investigation findings. THIS IS AN AMENDED LIC9099 DUE TO NEW INVESTIGATIVE FINDING FROM UNSUBSTANTIATED TO UNFOUNDED.

On 3/22/2021, the Department received a complaint of the above allegations. On 3/30/2021, an unannounced complaint inspection visit was conducted. During the investigation, LPA interviewed administrator (ADM) Jocelyn Real and toured the facility. LPA observed 3 staff (S1 - S3) and 5 residents (R1 - R5) in the facility. Residents and staff rosters, facility food menu, resident physician reports, resident appraisal/needs and service plans, house keeping schedule, current staff duty schedule, LIC500 Personnel Report, and staff training log were obtained

Continued, see LIC 9099-C, pages 2 of 3

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

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-20210322110613

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: REAL ELDERLY CARE	FACILITY NUMBER: 435202779
	VISIT DATE: 11/10/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff member is not qualified in taking care of residents:
On 03/30/2021 and 04/30/2021, LPA interviewed ADM. ADM has 7 years of experience providing direct care. ADM worked as a caregiver, as a Lead Staff, as a House Manager and as an Administrator. ADM stated ADM knows how to lead the team, how to train staff. ADM stated the facility provides all facility staff training regularly. ADM submitted the facility staff training log to LPA. There are 40 hours training for each staff including CARE for DEMENTIA: What is Dementia, Symptoms, Causes, Diagnosis, Treatments, Prevention; Food Preparation; Medication Review; Incident Report; Emergency Protocol; Hospice Training; Disaster Training; Depression; Wound Care; and Monitoring Compliance. LPA interviewed ADM for COVID protocol and reviewed LIC808 with ADM. ADM has the knowledge about COVID protocol and LIC808, Mitigation Plan. LPA interviewed ADM for the compliance, regulations, and Title 22. ADM has the knowledge of Title 22.

ADM stated the facility provides the infection control/prevention training for all the staff.

Continued, see LIC 9099-C, pages 3 of 3

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 26-AS-20210322110613

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: REAL ELDERLY CARE	FACILITY NUMBER: 435202779
	VISIT DATE: 11/10/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The Department has investigated the above allegations. Based on the investigation, observations, records reviewed, and interviews conducted, the Department found that the
above allegations are UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. This report was provided to ADM for signature. A copy of this report was emailed to ADM.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3