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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202818
Report Date: 05/10/2024
Date Signed: 05/10/2024 05:52:42 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
12/27/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20231227155220
FACILITY NAME:OAKMONT OF SAN JOSEFACILITY NUMBER:
435202818
ADMINISTRATOR:PAULA SPANEKFACILITY TYPE:
740
ADDRESS:917 THORNTON WAYTELEPHONE:
(408) 371-7100
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:92CENSUS: 56DATE:
05/10/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Christopher SchusterTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility failed to seek timely medical attention which resulted in resident hospitalization
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to deliver the complaint investigating finding regarding the above allegations. LPA met with Interim Executive Director, Christopher Schuster.

On 12/27/2023, the Department received a complaint alleging facility staff failed to seek timely medication attention which resulted in resident hospitalization. On 01/05/2024, the initial complaint investigation was conducted.

The following documents were obtained to include resident (R1 – R5’s) records: physician’s report, individualized service plan, resident assessment, charting notes, medication administration record (MAR), resident roster, traditions shower schedule, and medical records. PAGE 1 OF 3.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
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 8
Control Number 26-AS-20231227155220
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 SAN JOSE
FACILITY NUMBER: 435202818
VISIT DATE: 05/10/2024
NARRATIVE
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On 12/26/2023, resident (R1) began to develop flu-like symptoms. R1’s responsible party was made aware. The review of records shows that on 12/26/2023 around 11:00PM, R1’s responsible party contacted the facility to follow-up on R1’s condition. R1’s responsible party instructed the facility staff to monitor R1’s condition as R1 was not feeling well. It was noted during NOC shift that R1 had on and off coughing and was not feeling well but slept through the night.

On 12/27/2023, between 6:30AM – 7:00AM, staff observed resident was sleeping. Around 8:00AM, staff checked R1. At 9:00AM, staff contacted R1’s responsible party regarding R1’s condition. R1 was observed to be wheezing, had a runny nose, and coughing. R1’s responsible party was stated to be on the way to the facility within an hour. Record review shows that after the telephone call to R1’s responsible party staff offered R1 breakfast, which R1 initially refused. Staff (S8) offered R1 yogurt and water, which R1 partially consumed prior to taking his/her medications. R1 was observed to be responsive but weak.

Around 10:00AM, R1’s responsible party arrived to the facility and observed R1 laying in bed, unresponsive, and pale in color. R1’s responsible party contacted emergency services and R1 was then transported to the hospital.

8 staff members were interviewed. 5 out of 8 staff interviewed were familiar with R1’s care. 1 out of 5 staff members stated the observation of R1 looking weak the night before he/she went to the hospital (12/26/2023). 5 out of 5 staff stated the observation of R1 feeling unwell the morning of 12/27/2023. Based on interview, staff did not offer to contact emergency medical services when the initial telephone call was made to the RP. Staff stated they did not offer to contact medical services because RP stated to be on the way.

The review of medical records shows that upon arrival of emergency medical services, R1 had an altered level of consciousness, shortness of breath, and a fever. R1 was hospitalized and diagnosed with a life-threatening infection and virus.

PAGE 2 OF 3.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Citations on this Visit Report are Under Appeal!

Control Number 26-AS-20231227155220
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 SAN JOSE
FACILITY NUMBER: 435202818
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
05/11/2024
Section Cited
CCR
87465(a)(1)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
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Licensee will submit a written plan to address the citation issued to LPA Dolores via email by POC due date.
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Based on interview, record review, and observation the licensee did not ensure to seek timely medication attention for resident (R1) resulting in hospitalization which poses an immediate health, safety, and 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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
12/27/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20231227155220

FACILITY NAME:OAKMONT OF SAN JOSEFACILITY NUMBER:
435202818
ADMINISTRATOR:PAULA SPANEKFACILITY TYPE:
740
ADDRESS:917 THORNTON WAYTELEPHONE:
(408) 371-7100
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:92CENSUS: 56DATE:
05/10/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Christopher SchusterTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff did not dispense medication according to doctor's orders
Facility visitor recording resident without consent
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to deliver the complaint investigating finding regarding the above allegations. LPA met with Interim Executive Director, Christopher Schuster.

On 12/27/2023, the Department received a complaint alleging staff did not dispense a resident’s medication according to doctor’s orders and a facility visitor recorded a resident without consent. On 01/05/2024, the initial complaint investigation was conducted.

The following documents were obtained to include resident (R1 – R5’s) records: physician’s report, individualized service plan, resident assessment, charting notes, medication administration record (MAR), resident roster, traditions shower schedule, and medical records. SEE LIC9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 26-AS-20231227155220
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 SAN JOSE
FACILITY NUMBER: 435202818
VISIT DATE: 05/10/2024
NARRATIVE
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On 12/26/2023, resident (R1) began to develop flu-like symptoms. Around 6:00PM, R1’s responsible party spoke with R1 who only speaks another language but English. R1 told his/her responsible party that his/her head was hurting all day and was not feeling well. The responsible party contacted staff and requested to dispense a PRN medication for R1. R1’s responsible party arrived to the facility about 45 minutes after the telephone call, and was informed by R1 that he/she has not yet received their PRN medication.

Based on record review, the physician’s order for R1’s PRN medication states an instruction for “as needed”.

R1’s PRN medication was dispensed around 8:00PM on 12/26/2023.

Throughout the investigation, 3 witnesses were interviewed. 3 out of 3 witnesses denied recording a resident without consent. 3 out of 3 witnesses denied the observation of another visitor recording a resident without consent.

7 out of 7 staff members interviewed denied the observation of a visitor recording a resident without consent

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. A case management visit was conducted due to a violation observed. See LIC809 on 05/10/2024.

This report was reviewed with Interim Executive Director, Christopher Schuster and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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
12/27/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20231227155220

FACILITY NAME:OAKMONT OF SAN JOSEFACILITY NUMBER:
435202818
ADMINISTRATOR:PAULA SPANEKFACILITY TYPE:
740
ADDRESS:917 THORNTON WAYTELEPHONE:
(408) 371-7100
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:92CENSUS: 56DATE:
05/10/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Christopher SchusterTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility staff retaliated against resident for making complaints
Staff did not meet resident’s showering needs
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to deliver the complaint investigating finding regarding the above allegations. LPA met with Interim Executive Director, Christopher Schuster.

On 12/27/2023, the Department received a complaint alleging facility staff retaliated against resident for making complaints and staff did not meet resident’s showering needs. It was alleged that the facility had retaliated against the resident (R1) by not providing shower services, restricting areas of the facility for a visitor, and increasing R1’s care fees. On 01/05/2024, the initial complaint investigation was conducted.

The following documents were obtained to include resident (R1 – R5’s) records: physician’s report, individualized service plan, resident assessment, charting notes, medication administration record (MAR)s from November – December 2023, resident roster, weekly shower schedules, and medical records. LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 26-AS-20231227155220
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 SAN JOSE
FACILITY NUMBER: 435202818
VISIT DATE: 05/10/2024
NARRATIVE
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Throughout the investigation, 7 staff members were interviewed. Based on interview, 6 out of 7 staff members stated R1 receives showers during his/her shower schedule days. 1 out of 7 staff members was not familiar with R1’s care as R1 was assigned to another group. S1 stated that staff were instructed to wait until R1’s family member arrived before staff could assist R1 with showers. S1 states that sometimes R1 needed to wait to be assisted with a shower if staff were busy assisting other residents.

The review of records indicates that R1 is scheduled for showers three times a week.

7 out of 7 staff members interviewed denied restricting any visitors in the facility. 7 out of 7 staff members denied restricting any areas of the facility for visitors.

Throughout the investigation, 3 witnesses were interviewed. 3 out of 3 witnesses denied being restricted visitation at the facility. 3 out of 3 witnesses denied the observation of any areas of the facility being restricted for other visitors.

The review of records indicates that from October 2023 – December 2023, R1’s care was increased to a total of 65 acuity points and 61 billable points. Care items that were increased from October 2023 – December 2023 included grooming, toileting, assistive devices, outside providers, restless behaviors, verbally disruptive behaviors, delusions and hallucination behaviors, and disturbed sleep behaviors.

7 out of 7 staff members were interviews. Based on interview, R1 required total care and full assistance with activities of daily living (ADL) care.

The Department has investigated the above allegations. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Interim Executive Director, Christopher Schuster and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 26-AS-20231227155220
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 SAN JOSE
FACILITY NUMBER: 435202818
VISIT DATE: 05/10/2024
NARRATIVE
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The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated.

An immediate civil penalty of $500 is being assessed today for serious bodily injury. Additional civil penalties are pending review.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC9099-D.

This report was reviewed with Interim Executive Director, Christopher Schuster and a copy of the report and appeal rights were provided.

PAGE 3 OF 3.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8