<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202818
Report Date: 11/01/2023
Date Signed: 11/01/2023 04:06:31 PM


Document Has Been Signed on 11/01/2023 04:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 JOSEFACILITY NUMBER:
435202818
ADMINISTRATOR:PAULA SPANEKFACILITY TYPE:
740
ADDRESS:917 THORNTON WAYTELEPHONE:
(408) 371-7100
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:92CENSUS: DATE:
11/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Paula SpanekTIME COMPLETED:
04:10 PM
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
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a continuation of a case management – incident visit from 08/04/2023. LPA met with Executive Director, Paula Spanek.

On 08/04/2023, LPA Dolores arrived to the facility to conduct as case management – incident visit based on an incident report and death report received for resident (R1).

On 08/04/2023, the Assistant Executive Director was interviewed. Documents were obtained throughout the investigation to include resident (R1)’s physician’s report, functional capabilities assessment, individualized care plan, face sheet, progress notes, medical records, fax notifications to physician, police report, verification of death, and death certificate.

Based on interview and record review, it was found that on 07/19/2023 resident (R1) was moved from Assisted Living to Memory Care due to a change of condition. Resident was noted to be a fall risk and sustained frequent falls in the community. On the morning of 07/28/2023, R1 sustained a first fall in Memory Care. R1’s family was notified via telephone and physician was notified via fax. The facility did not conduct a re-assessment for R1 after the first fall in memory care. On the night of 07/28/2023, R1 sustained a second fall. Resident did not complain of any pain or discomfort. Staff continued to monitor R1's condition post-fall. Based on record review, there was no indication R1’s family or physician was notified of the second fall. On the night of 07/29/2023, R1 sustained a third fall and was pronounced deceased by the paramedics.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Executive Director, Paula Spanek and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 11/01/2023 04:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/02/2023
Section Cited
CCR
87463(a)

1
2
3
4
5
6
7
(a) ... The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidence by:
1
2
3
4
5
6
7
Licensee will submit a statement of understanding of section 87463 and written plan of action going forward to ensure compliance. Licensee will submit the POC to LPA Dolores via email by POC due date.
8
9
10
11
12
13
14
Based on interview, record review, and observation the licensee did not ensure to re-assess resident (R1) after sustaining a fall in memory care which poses/posed an immediate health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
Request Denied
Type A
11/02/2023
Section Cited
CCR87463(b)

1
2
3
4
5
6
7
(b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will provide an in-service training to staff regarding notification and communications to family and physician's. Licensee will submit the POC to LPA Dolores via email by POC due date.
8
9
10
11
12
13
14
Based on interview, record review, and observation the licensee did not ensure to inform the resident's responsible party and physician after resident (R1) sustained a second fall on the same day which poses/posed an immediate health safety and 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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2