435202818-5-10-2024-26-AS-KHOS-D5WP7L-20240604110406

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202818
Report Date: 05/10/2024
Date Signed: 05/10/2024 05:18:35 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2023 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20231027084308

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: 56	DATE:	05/10/2024
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Christopher Schuster		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Resident sustained a pressure injury due to staff neglect
Staff did not administer resident's medication
Staff left resident in soiled diapers for an extended period of time
Staff are not meeting residents needs
Facility does not have adequate staff is memory care to meet the residents needs

INVESTIGATION FINDINGS:

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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: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

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 10

Control Number 26-AS-20231027084308

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: OAKMONT OF SAN JOSE	FACILITY NUMBER: 435202818
	VISIT DATE: 05/10/2024

NARRATIVE

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LPA Dolores interviewed a staff member (S1) and it was mentioned that when they we redoing the assessment for R1, RP didn’t allow the staff to check R1s skin. RP told there’s no pressure injury and R1 has redness on the bottom but it’s okay. Upon moving in, the Health Services Director (HSD) wasn’t here. They weren't able to do the skin check upon move in day. It was reported later that there was a tiny opening of .5 cm. HSD checked it and reported it to RP, doctor, and requested home health when they found out there was an opening. There is a PRN cream that needs to be applied. Normal procedure is to do a skin check prior to move in but RP was saying no need to because R1 doesn’t have any issues. That’s the only one that they didn’t do the skin check for. Another staff member, S5, mentioned that R1 has some type of pressure injury and it was not staged. During the pre-assessment there was redness but didn’t check R1s skin. Family didn’t let them check the skin.

LPA Donato was able to interview the Home Health Nurse and it was confirmed that the pressure injury was at stage two.

Based on records review, a charting report showed that on 12/16/2023 input by S6 at 9:30PM that R1 had a blister on left heel and Tylenol was given for pain and discomfort.

Regarding the allegation of staff did not administer resident's medication, RP stated that R1 has butt paste to prevent R1 from getting pressure sores and the staff haven’t been putting it on.

LPA Donato reviewed the Medication Administration Records (MAR) of R1, and it shows that the cream that was prescribed as needed (PRN) and had a direction of being applied topically each bowel movement/diaper change was not done regularly. MAR from October 19-31 2023 showed the cream was only applied for seven random days. MAR from November 2023 also showed cream being applied three to four random days.

...PAGE 2 of 4

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2023 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20231027084308

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: 56	DATE:	05/10/2024
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Christopher Schuster		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Staff are not providing adequate food service to residents

INVESTIGATION FINDINGS:

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On 5/10/24, Licensing Program Analysts (LPAs) Grace Donato & Christine Dolores conducted an unannounced complaint investigation visit. LPAs met with Interim Executive Director, Christopher Schuster and LPA explained the purpose of today's visit.

Regarding the allegation of staff are not providing adequate food service to residents, RP stated that it was observed residents sitting with food in front of them getting cold waiting to be fed. RP stated that he/she has seen residents trying to feed themselves and dropping food or drinks because they need assistance with eating.

LPA Dolores interviewed five staff members. S2 mentioned that there are residents who need feeding. There is one under S2s group but it’s on and off. S2 just needs to cue them cause they’re independent. S3 has two residents in the group. S2 also mentioned that they have a lot of teamwork. Residents are provided three meals and four snacks throughout the day. All care staff helps during meals. S3 assists them during meals, give them drink, soup and cutting food.

Based on interviews, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided.

Unsubstantiated

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: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2023 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20231027084308

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: 56	DATE:	05/10/2024
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Christopher Schuster		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Unqualified staff providing care to residents

INVESTIGATION FINDINGS:

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On 5/10/24, Licensing Program Analysts (LPAs) Grace Donato & Christine Dolores conducted an unannounced complaint investigation visit. LPAs met with Interim Executive Director, Christopher Schuster and LPA explained the purpose of today's visit.

Regarding the allegation of unqualified staff providing care to residents.

LPA Dolores interviewed five staff members. S2 mentioned that they receive in-service training every two weeks. Safety, transferring, resident care, skin tears and service and answering calls. They also assist residents with all ADLs, transferring, escorting, monitoring and conditions and notify the med tech, report and meet their needs. S3 stated that they had training to fully assist, transferring, showering, changing diapers. S3 also did training for two days in the computer and three days on the floor. S4 said that they had a lot of training regarding dementia, how to care for residents, CPR and food.

...PAGE 1 of 2

Unfounded

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: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 10

Control Number 26-AS-20231027084308

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: OAKMONT OF SAN JOSE	FACILITY NUMBER: 435202818
	VISIT DATE: 05/10/2024

NARRATIVE

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LPA Donato did a records review and facility was able to provide documentation for in service training regarding Resident Fall Management, Proper Positioning, Bowel Protocol and annual trainings for Dementia Care-Performing ADLs (Activities of Daily Living) and Assisting with ADLs.

Based on interviews and records review, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

Report is reviewed and copy is provided.

...PAGE 2 of 2

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 10

Control Number 26-AS-20231027084308

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: OAKMONT OF SAN JOSE	FACILITY NUMBER: 435202818
	VISIT DATE: 05/10/2024

NARRATIVE

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Regarding the allegations of staff left resident in soiled diapers for an extended period of time and Staff are not meeting resident’s needs, RP stated that R1 is not being changed enough and ends up with soaked diapers and clothing. RP stated that the staff have even put double diapers on R1 to get out of changing her.

Based on records review, a photo evidence was submitted by RP showing a soiled double diaper that was removed from the resident. On R1s individualized service plan dated 10/16/23, it is noted that R1 takes a medication which makes R1 urinate a large amount up to six hours after the first dose so R1 needs to go frequently to toilet. An document was obtained acknowledging that RP addressed the double diapers to the facility and that facility acknowledged this and stated that it will address the situation.

LPA Dolores interviewed five staff members. S2 mentioned that he/she doesn’t know of any soiled diapers. S3 stated that R1 is not left for a long time and changes R1s diaper as soon as needed.

Regarding the allegation of facility does not have adequate staff in memory care to meet the resident’s needs, RP stated that there is not enough staff to handle the residents in memory care.

Based on records review, the month of October 2023 there are three to four caregivers scheduled per shift and this does not include the med tech. Shift times start at 6am to 2pm, 2pm to 10pm and NOC shift, 10pm to 6am has 2 staff scheduled.

During the interview, S2 mentioned that they are not short staffed in memory care. S2 has seven residents under his/her care. S3 stated that they normally have the same groups of residents and currently has six in the group. S4 stated that there are usually three caregivers. On Wednesday and Thursdays there are four. S4 is the extra and they have enough staff to care for the residents. S4 also mentioned that there are three caregivers on the floor and med tech steps in. Ratio is one caregiver is to six or seven residents. Time management is very important, so they can meet their needs.

...PAGE 3 of 4

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 10

Control Number 26-AS-20231027084308

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: OAKMONT OF SAN JOSE	FACILITY NUMBER: 435202818
	VISIT DATE: 05/10/2024

NARRATIVE

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However, S3 also mentioned that R1 needs a diaper change about four to five times during the shift. R1 also is not able to go to the bathroom unassisted. S5 also mentioned that R1s toileting happens every two hours. R1 has diaper changes around four to five times and during night shift will be two to three times.

Based on interviews, 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 deficiency was cited during today’s visit, see LIC809-D. A civil penalty for repeat violation within the 12-month period is being assessed for the amount of $250, see LIC421FC.

Additional civil penalties are pending review.

A copy of this report and the Appeal Rights are provided.

...PAGE 4 of 4

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 10

Control Number 26-AS-20231027084308

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: OAKMONT OF SAN JOSE	FACILITY NUMBER: 435202818
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 05/11/2024 Section Cited CCR 87457(a)(2)	1 2 3 4 5 6 7	87457 Pre-Admission Appraisal – General (a)Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. (2) The prospective resident's desires regarding admission, and his/her background, including any specific service needs, medical background and functional limitations shall be discussed.	1 2 3 4 5 6 7	Licensee to submit a plan on how to address Pre-Admission Appraisals for future residents. Licensee to submit by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above due to staff wasn't able to conduct skin check to determine if there is pressure injury on R1 prior to admission which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Request Denied Type A 05/11/2024 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly (2)Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Licensee to submit a plan and in-service training regarding medication administration. Licensee to submit by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interview and records review, the instructions of the PRN medication prescribed by the physician was not followed. Medication was only applied on random days, not every change in diaper or bowel movement 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: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC9099 (FAS) - (06/04)

Page: 8 of 10

Control Number 26-AS-20231027084308

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: OAKMONT OF SAN JOSE	FACILITY NUMBER: 435202818
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 05/11/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning... 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...	1 2 3 4 5 6 7	Licensee to submit a plan and in-service training Observation of Resident. Licensee to submit by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interview and records review, RP noticed the blister and then made the facility and physician aware, which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Request Denied Type A 05/11/2024 Section Cited CCR 87463(a)(3)	1 2 3 4 5 6 7	87463 Reappraisals (a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate...Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition...	1 2 3 4 5 6 7	Licensee to submit a plan to address Reappraisals of resident. Licensee to submit by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interview and records review, facility did not do a reappraisal based on the need of R1 for toileting due to a medication that causes her to urinate a large amount 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: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC9099 (FAS) - (06/04)

Page: 9 of 10

Control Number 26-AS-20231027084308

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: OAKMONT OF SAN JOSE	FACILITY NUMBER: 435202818
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 05/11/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care...	1 2 3 4 5 6 7	Licensee to submit a plan and in-service training regarding medication administration. Licensee to submit by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews, R1 needed more assistance with incontinence and there was not enough staff to be able to cater for the needs of R1 which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC9099 (FAS) - (06/04)

Page: 10 of 10