435202818-2-21-2024-26-AS-KHOS-D4CMJM-20240415093923

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202818
Report Date: 02/21/2024
Date Signed: 02/21/2024 04:57:07 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
12/07/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20231207102825

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: 58	DATE:	02/21/2024
		UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Paula Spanek		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not administer resident's medication as prescribed.
Staff did not notice resident's change of condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding for the above allegations. LPA met with Executive Director (ED) Paula Spanek.

On 12/07/2023, the Department received a complaint alleging staff did not administer resident’s PRN medication as prescribed and staff did not notice resident’s change of condition. 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, progress notes, medication list, MAR from November - December 2023, home health progress notes from October 2023 – November 2023, and correspondence. PAGE 1 OF 3.

Substantiated

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: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

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 4

Control Number 26-AS-20231207102825

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: 02/21/2024

NARRATIVE

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From 02/02/2024 - 02/21/2024, 9 staff members were interviewed. Based on staff interview, staff are to monitor the resident’s bowel movements daily. Staff document their observation in a bowel movement log which is shredded at the end of every month. If a resident were to not have a bowel movement for 3 days, the caregivers are to report to the Medication Technician. The Medication Technicians then follows their procedures which includes but limited to reporting to the facility’s directors, responsible party, and physician.

Based on record review R1 is diagnosed with a neurocognitive impairment and is not able to administered own PRN medication. Facility staff assists resident with the administration of all medications. On 11/22/2023, R1’s home health nurse noticed that R1’s last documented bowel movement was on 11/16/2023 and the facility staff was informed of the observation. The review of records show that R1 has a PRN order for constipation medication with instructions to take 1 tablet daily as needed for constipation. From 11/17/2023 – 11/21/2023, there was no documentation regarding the observation of R1's bowel movements. Based on record review, R1 was only administered the PRN medication for constipation on 11/16/23, 11/22/23, 11/23/23, 11/24/23, and 11/25/23. Records show that R1 was not administered a PRN medication for constipation between 11/19/23 – 11/21/23, which counts 3 days after R1 had a last documented bowel movement.

Based on staff interview, staff are instructed by R1’s responsible party to inform the responsible party first, before any PRN medications are administered. Based on record review, there are no notes or documentation that R1’s family member was informed that R1 had not had a bowel movement for over 3 days and the request to administer the PRN medication. Based on record review, the facility was also unable to provide documentation that R1's physician was notified of R1's condition of constipation from 11/19/2023 - 11/21/2023, which counts 3 days after R1 had a last bowel movement.

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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: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20231207102825

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: 02/21/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 02/22/2024 Section Cited CCR 87465(d)	1 2 3 4 5 6 7	(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will provide an in-service training to all staff regarding reporting. Licensee will provide the in-service training document 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 assist R1 with a prescribed PRN medication for constipation after it was noted that R1 had not had a BM for more than 3 days which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
Request Denied Type A 02/22/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will provide an in-service training to all staff regarding proper documents for changes of conditions. Licensee will provide in-service training document 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 that staff documented and informed the resident's physician and family member of their observation of R1's last bowel movement being over 3 days which poses 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 Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20231207102825

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: 02/21/2024

NARRATIVE

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Based on staff interview, 9 out of 9 staff was unaware that R1 had gone over 3 days without having a bowel movement.

The Department has investigated the above allegations and the preponderance of evidence standard has been met, therefore, the above allegations are substantiated. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Executive Director (ED), Paula Spanek and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4