435202818-8-26-2024-26-AS-KHOS-D92RR7-20240912131440

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202818
Report Date: 08/26/2024
Date Signed: 08/26/2024 12:02:38 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
12/05/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20231205162429

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: 65	DATE:	08/26/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Kippie Castronovo		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Resident sustained an unexplained bruise while in care
Staff handled resident in a rough manner
Staff spoke and yelled at resident in an inappropriate manner
Staff is unable to meet residents needs with a sprained arm

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to deliver the finding regarding the above allegations. LPA met with Executive Director, Kippie Castronovo.

On 12/05/2023, the Department received the complaint regarding the above allegations. On 12/14/2023, the initial complaint investigation was conducted.

The following documents were obtained to include resident (R1)'s physician's report, appraisal/needs and services plan, medication administration record, progress notes, third party communication forms, resident roster, staff roster, staff schedule from November - December 2023, staff members contact information, S1’s physician's note regarding injury, email correspondences, incident report, and police reports.
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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: 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)

Page: 1 of 5

Control Number 26-AS-20231205162429

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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It was alleged that on 11/28/2023, R1’s responsible party found a bruise on R1’s arm and the staff was unable to explain how it happened.

The review of the photograph shows a purple and reddish discoloration measuring approximately 3-4 inched (linear) on the right forearm.

On 11/28/2023, R1’s responsible party notified the facility staff via email regarding the observation of a long bruise on R1’s arm. Based on the email, R1 denied any pain and did not recall how it happened. It was stated they were thinking it could have happened at the exiting doorways or when R1 moved in and out of the dining table. R1’s responsible party advised staff to be extra careful when maneuvering R1 in the wheelchair since R1 is on a certain medication.

On 11/29/2023, the facility staff (S3) replied stating that S3 was with R1 and did not notice any bruising on R1’s arm. It was stated that the care staff put lotion on R1 and did not notice the bruising the last two days either. It was stated that S3 checked in on R1 that morning and seemed to be okay with no complaints of pain. S3 states to believe the bruise was from the wheelchair because R1 rests and puts pressure on the arm rest.

10 staff members were interviewed. S6 states to have seen the bruise but was unsure on how R1 sustained the bruise. S6 states to not have noticed the bruise because R1 was wearing a long sleeve that day and that he/she only changes R1 into pajamas when R1’s responsible party arrives. S6 noticed the bruise when changing R1’s clothes and reported the observation to the Medtech. Staff (S4) (S5) and (S7) believed that the bruise was from R1’s wheelchair. S4 and S5 states R1’s sleeps on the wheelchair and would lean on the arm rest.

Based on record review, the facility’s noted their observations of R1 per each shift from 11/25/23 – 12/2/2023. There was no note regarding the observation of any bruising on R1’s skin prior nor incidents that may have caused the bruising prior to 11/28/2023. R1 was also receiving services from a third party and based on the records, the resident was unable to recall what happened. It was noted that the bruise was possibly from the old wheelchair. 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: 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)

Page: 2 of 5

Control Number 26-AS-20231205162429

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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It was alleged that R1 reported to his/her responsible party on 11/25/2023 that a staff yelled and “was really rude and mean and rough” with R1 during the night shift. It was also alleged that on 12/02/2023, R1 reported to his/her responsible party that a staff was rough with him/her during the night shift and pushed R1’s shoulder while changing him/her and spoke aggressively to R1.

11 staff members were interviewed regarding the allegation of rough handling a resident. 11 out of 11 staff members denied any staff handling residents in a rough manner. 11 out of 11 staff members denied the observation of another staff handling R1 in a rough manner.

11 staff members were interviewed regarding the allegation of staff speaking and yelling at a resident in an inappropriate manner. 11 out of 11 staff members denied speaking inappropriately to residents. 11 out of 11 staff members denied the observation of staff speaking inappropriately to residents.

On 12/14/2023, 2 residents were interviewed. LPA Dolores was unable to properly interview R1 due to behaviors the resident began to experience during the interview. R2 stated the staff are for the most part gentle when caring for R2. R2 denied staff yelling at him/her or other residents.

The review of the facility’s records shows that the facility was notified on 12/01/2023 by R1’s responsible party that a NOC staff (S1) was being rough and talking in an angry voice. This was reported by R1 to R1’s responsible party. There is no record showing the facility was notified of the alleged incident on 11/25/2023.

Based on record review, from 11/25/23 – 12/2/23 R1 was observed during the NOC shift. On 12/1/23, it was noted that R1 slept through the whole night but didn’t want to change and hit the care staff. R1’s care was then endorsed to the morning care staff.

Record shows that on 12/02/2023, the facility staff conducted an internal investigation. Based on the records, the resident stated all staff treats R1 very well and R1 is not being treated badly or rough. 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: 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)

Page: 3 of 5

Control Number 26-AS-20231205162429

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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On 12/05/2023, the police were called to the facility. Based on review the report, R1 stated that a suspect had hit him/her in the head with his/her hand and a diaper while changing R1. R1 attempted to defend him/herself and the suspect held R1 down causing R1 to sustain a bruise on his/her arm. R1 described the physical appearance of the suspect. A staff verified the suspect’s name, but the last name was handwritten and illegible based on the list that was provided. It was indicated that the suspect was unidentified and still at large.

The review of the staffing schedule shows that 2 NOC staff was scheduled during the night of 12/01/23 and 12/02/23, to include S1.

Based on interview with S1, S1 states to not have done anything to wrong to R1. S8 stated to have witnessed one night when R1 refused to be changed and smacked S1’s hand. S8 stated that R1 was agitated so they both agreed to try again later. S8 denied S1 being rough and speaking inappropriately to R1.

The review of R1’s records shows that R1 is diagnosed with a major neurocognitive disorder.

Staff is unable to meet residents needs with a sprained arm
It was alleged that on 11/26/2023 staff (S2) was working with a sprained arm and was unable to assist R1 when requested by R1’s responsible party. It was alleged that R1’s legs were misaligned in the wheelchair and R1 was crying for help and S2 did not attempt to get help.

Based on record review, S2 had a physician’s note which included modified activity and restrictions.

9 staff members were interviewed regarding this allegation. Based on interview, it was stated that S2 did have a sprained arm, however, was not assigned as a caregiver. S2 was assigned to complete computer work instead.
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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
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)

Page: 4 of 5

Control Number 26-AS-20231205162429

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 interview with staff (S2), it was stated that due to S2’s limitations, S2 was not caregiver and was only assigned to computer work. S2 stated to be in the common area because another staff needed to do something. S2 was supervising the residents for a moment while the caregiver stepped away and while S2 was in the common area, R1’s family member asked for help in which S2 apologized as S2 was unable to assist due an injury. It was stated that shortly after, S2 followed-up with a caregiver to inform the caregiver of the situation, in which that caregiver was able to assist R1.

Based on the facility’s memory care staffing schedule for November 2023, there was at least 3 – 4 caregivers scheduled in the PM and 2 staff during NOC. S2 was not part of the list of caregivers scheduled during the date this incident was alleged on 11/26/2023.

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 a violation 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.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
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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