435202818-7-18-2024-26-AS-KHOS-D92QU6-20240912122814

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202818
Report Date: 07/18/2024
Date Signed: 07/18/2024 04:18:57 PM

Unsubstantiated

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
11/06/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20231106161659

FACILITY NAME:	OAKMONT OF SAN JOSE		FACILITY NUMBER:	435202818
ADMINISTRATOR:	PAULA SPANEK		FACILITY TYPE:	740
ADDRESS:	917 THORNTON WAY		TELEPHONE:	(408) 371-7100
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	92	CENSUS: 62	DATE:	07/18/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Kippie Castronovo		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not attend to resident in care in a timely manner
Staff did not report resident’s incident to resident’s representative
Facility is not treating a resident’s visitor with dignity
Facility financially retaliated against resident

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Christine Dolores, Grace Donato, and Kiran Jain arrived unannounced to deliver the finding for the above allegations. LPA met with Executive Director Kippie Castronovo.

On 11/06/2023, the Department received the complaint regarding the above allegations. On 11/16/2023, the initial complaint investigation was conducted.

The following documents were obtained for this investigation to include the staff schedule from October 21, 2023 to October 26, 2023, call button report from November 1, 2023 to November 30, 2023, resident (R1)’s admission agreement, physician’s report, cares assessments, charting notes for November 2023, third party communication notes, special care instructions, and other correspondences.

PAGE 1 OF 5

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

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 5

Control Number 26-AS-20231106161659

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: 07/18/2024

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 do not attend to resident in care in a timely manner
On 11/06/2023, it was alleged that the facility staff do not attend to resident (R1) in a timely manner when R1 calls out for help and that no one comes to R1 “for a very long time”. The concern was that staff are unable to hear R1 crying for help as R1’s room was located in the back corner.

During the course of this investigation, 10 staff members were interviewed. Based on interview, 10 out of 10 staff state that staff attend to R1 when R1 they hear R1 calling for assistance. It was stated that if staff are busy assisting other residents, then it’s difficult for staff to get to R1 right away. It was stated that the facility frequently checks in with the residents, but they do not have a specific timeframe for how frequently staff are required to check in with the residents. 9 out of 10 staff stated they check in with the residents every 1-2 hours. 1 out of 10 staff stated they conduct “frequent checks” but was unable to elaborate more on the timeframe. It was stated that residents who require more care needs are checked on more often.

Based on staff interviews, it was stated that due to R1’s needs, the facility recommended a 1:1 caregiver for R1 during the night however due to financial reasons, R1 was unable to be provided a 1:1 caregiver. Due to R1’s behaviors during the night, the facility temporarily implemented a NOC shift staff to sit with R1 during the night. It was stated that the staff tried to their best to accommodate to R1’s needs. It was stated that due R1’s behaviors during the night, the facility provided R1 a pendant on 11/08/2024.

Staff did not report resident’s incident to resident’s representative
On 11/06/2023, It was alleged that the facility staff did not report a resident’s fall incident on the night of 10/21/2023 to the R1’s representative/responsible party. The fall incident was verbally reported by R1 to R1’s responsible party and a home health agency nurse. It was reported to R1’s responsible party that R1 fell while being assisted by staff to bed on 10/21/2024. R1’s responsible party informed the facility staff regarding the fall.

PAGE 2 OF 5

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20231106161659

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: 07/18/2024

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

Based on record review, there were no notes in R1’s file regarding a fall on 10/21/2023. On 10/22/2023, it was noted that R1’s responsible party claimed the bruise on R1’s buttocks was a result of a fall from the night of 10/21/2023. Staff informed R1’s responsible party that there were no reports regarding any falls.

5 staff members were interviewed regarding the allegation. Based on interview, 5 out of 5 staff denied the observation and knowledge of R1’s witnessed fall on the night of 10/21/2023. It was stated that R1 reported the fall to R1’s responsible party, who then reported the fall to the facility staff. When staff was made aware of the fall, R1’s responsible party did not allow staff to ask R1 additional questions regarding the fall. The facility conducted their internal investigation and staff did not report any witnessed falls or incidents with R1 that night of 10/21/2023. It was stated that because there was no report regarding R1’s fall, the facility treated the incident like it never happened.

2 staff stated the observation of a bruise on R1’s buttocks but did not know where the bruise came from. Staff endorsed the observation and continued to monitor R1’s bruise.

1 witness (W1) was interviewed. Based on interview, W1 denied the observation or knowledge of a witness fall. W1 denied the observation of seeing a bruise on R1’s buttocks that resulted from a fall.

Facility is not treating a resident’s visitor with dignity
On 11/06/2023, the reporting party (RP) alleged that the facility staff is not treating a resident (R1)’s visitor with dignity. It was alleged that the facility was told by management to monitor R1’s responsible party’s visitation by informing the facility’s management when R1’s visitor arrives and departs from the facility.

Based on staff interview, all visitors in the community are required to abide to the same visitation policy and procedures. All visitors are required to sign in at the front desk and the front desk monitors the time the visitor departs from the facility. If visitors are in the community after 8:00PM, the staff should be aware of the visitation for safety reasons.
PAGE 3 OF 5

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20231106161659

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: 07/18/2024

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

9 staff members were interviewed regarding the allegation. Based on interview, 9 out of 9 staff denied monitoring any resident’s visitors in the community to include memory care. 9 out of 9 staff members denied monitoring R1’s visitor when in the community. 9 out of 9 staff members denied the requirement to inform management when R1’s visitor arrived or departed from the facility.

During staff interviews, it was stated that after 8:00PM the concierge leaves and staff walk the visitors out because the doors are locked. One night, staff needed to walk R1’s visitor out and R1’s visitor randomly commented telling the staff to text his/her boss that R1’s visitor is leaving. Staff stated to not know why R1’s visitor commented that and ignored the comment. Staff denied having to inform the facility’s management when R1’s visitor arrived or departed from the facility.

Facility financially retaliated against resident
On 11/06/2023, it was alleged that the facility financially retaliated against R1 by increasing R1’s care fees.

1 witness (W1) was interviewed. Based on interview, the facility raised the resident’s rate because of R1’s 2 falls. It was stated that the facility was “nit-picking” R1’s DPOA and it seemed to be retaliating. It was stated that there was no concern with the care and quality of care the facility provides R1, and everything seemed to be towards R1’s DPOA.

Based on record review, R1 had an initial assessment dated 10/13/2023 (move-in date). On 11/02/2023, the care assessment was drafted to include the increase of care. R1’s assessment on 10/13/2023 and 11/02/2023 was compared and the assessment on 11/02/2023 shows the increase of care to include grooming, toileting, fall management, time/place orientation, and behaviors to include restless, verbally disruptive, delusions and hallucinations, and combative.

PAGE 4 OF 5

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20231106161659

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: 07/18/2024

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

Based on staff interview, it was stated that after 2 weeks of the resident’s admission they check and reassess the resident to ensure they have the right care plan. On 11/02/2023, a draft of the increased care assessment was provided to the reporting party but the care increase was not carried out and was only a draft. It was stated that the care increase did not start as they haven’t had another care meeting to discuss the increase of care. It was stated the increase of care was because R1 actually required more care based on their observations after R1 moved into the facility.

10 staff members were interviewed regarding the allegation. Based on interview, R1 required total care and full assistance with activities of daily living (ADLs) to include mobility, transferring, toileting, showering, and grooming.

The review of R1’s records show that from 10/14/2024 – 11/02/2024, facility observed and noted their observations of R1 to include grooming (showers), toileting, 1 fall, and behaviors to include yelling and crying for staff, delusions and hallucinations, and combativeness with staff.

The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are 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 allegations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Executive Director, Kippie Castronovo and a copy of the report was provided.

PAGE 5 OF 5

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5