435202818-8-26-2024-26-AS-KHOS-D8RGAG-20240903051015

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202818
Report Date: 08/26/2024
Date Signed: 08/26/2024 12:28:29 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
05/17/2022 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20220517124344

FACILITY NAME:	OAKMONT OF SAN JOSE		FACILITY NUMBER:	435202818
ADMINISTRATOR:	SILVA, FLAVIO		FACILITY TYPE:	740
ADDRESS:	917 THORNTON WAY		TELEPHONE:	(408) 371-7100
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	92	CENSUS: 65	DATE:	08/26/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Kippie Castronovo		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not maintain accurate resident records
Staff disclosed resident confidential records with unauthorized person

INVESTIGATION FINDINGS:

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On 8/26/2024, Licensing Program Analysts (LPAs) Grace Donato & Christine Dolores conducted an unannounced complaint investigation visit. LPA met with Executive Director Kippie Castronovo and explained the purpose of today's visit.

Regarding the allegation of staff did not maintain accurate resident records, Reporting Party (RP) stated that facility failed to keep a complete and current record for resident (R1). Per the RP, the listed Primary Physician PCP and Pharmacy were in error, Facility has not updated "Diagnoses" on records to include R1s diagnosis of Acute Low Salt Syndrome.

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Substantiated

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: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

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-20220517124344

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: 08/26/2024

NARRATIVE

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Based on records review, LPA Donato was able to obtain three physicians reports (LIC602). The reports from 1/11/2019 and 10/26/2020 were from the first primary physician (PCP1) of R1. On the face sheet provided by the facility to the RP, with the print date of 11/29/2021, the physicians (PCP2) name did not match the LIC602. PCP2 has never met R1, nor signed any LIC602 for R1. The diagnosis of Acute Low Salt Syndrome was never mentioned in any LIC602. The name of the pharmacy has been updated to the current one during that time.

Regarding the allegation of staff disclosed resident confidential records with unauthorized person, RP stated that facility breached Confidentiality and Privacy of Records by forwarding, to RP, Residents (R2), covid-19 test results, dated 02/03/2022, without permission or authorization.

LPA Dolores interviewed two staff members. S1 stated that there was an incident where staff(S3) mistakenly shared R2s test with another family member. S3 admitted to sending the test to RP unintentionally.

Based on records review, LPA Dolores received copy of the said report from RP.

Therefore, based on interviews and records review and information collected, the above allegations are
determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22
cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

A copy of this report and the Appeal Rights are 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: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20220517124344

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: 08/26/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/21/2024 Section Cited CCR 87506(b)(9)	1 2 3 4 5 6 7	87506 Resident Records (b) Each resident’s record shall contain at least the following information: (9) Name, address and telephone number of physician and dentist to be called in an emergency. This was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit an audit report of records. Licensee to submit on POC due date.
	8 9 10 11 12 13 14	Based on records review, R1s PCP is not the correct physician in the face sheet, which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 08/21/2024 Section Cited CCR 87506(c)	1 2 3 4 5 6 7	87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential. This was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to do in-service training regarding confidentiality of records. Licensee to submit proof of training by POC due date.
	8 9 10 11 12 13 14	Based on record reviews, RP was able to receive a covid report of another resident which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC9099 (FAS) - (06/04)

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