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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202818
Report Date: 09/06/2024
Date Signed: 09/06/2024 12:25:13 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
05/18/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220518114814
FACILITY NAME:OAKMONT OF SAN JOSEFACILITY NUMBER:
435202818
ADMINISTRATOR:SILVA, FLAVIOFACILITY TYPE:
740
ADDRESS:917 THORNTON WAYTELEPHONE:
(408) 371-7100
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:92CENSUS: 82DATE:
09/06/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Sherry TheamTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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9
Staff are not following Covid-19 protocols
Staff administered unsanitary medication to resident
INVESTIGATION FINDINGS:
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On 9/6/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Memory Care Director Sherry Theam and explained the purpose of today's visit.

Regarding the allegation of staff are not following Covid-19 protocols, Reporting Party (RP) stated that staff member (S5) did not follow protocol by dressing in PPE and entering a room, which has PPE located in stacked containers, outside the room. S5, along with an "Agency Caregiver," stood outside the room, engaging in a conversation while the sick resident (R2) stood in the doorway. R2 was not wearing mask. Another instance mentioned was, Care Provider (S2) delivering the dinner tray to Room and did not dress in the PPE, located outside the room, prior to entering. S2 sounded raspy and sick too, and was wearing only a surgical mask, not a N95 mask to protect the Residents. S2 did not use the hand sanitizer, located outside the room, after exiting.

page 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
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 7
Control Number 26-AS-20220518114814
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: 09/06/2024
NARRATIVE
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Based on records review, LPA Donato referred to PIN 21-38-ASC regarding masking. It states that All ASC (Adult Senior Care) residential facilities must strictly adhere to current CDPH Masking Guidance. During the time of the complaint the applicable California Department of Public Health (CDPH) Guideline, dated March 14, 2022, states that masks are required for all individuals in the following indoor settings, regardless of vaccination status. Surgical masks or higher-level respirators (e.g., N95s, KN95s, KF94s) with good fit are highly recommended, Long Term Care Settings & Adult and Senior Care Facilities. LPA Dolores was able to obtain a photo showing S2 leaving the room of R2 and wearing only mask. No other PPEs was worn or removed.

LPA interviewed S5, and it was mentioned that there was an incident when a resident's family member saw S5 not wearing a mask. S5 had been eating or drinking something and forgot to put the mask on again. S5 knows masks are mandated in care facilities.

Regarding the allegation of staff administered unsanitary medication to resident, RP stated that S7 dropped R1s medication on the floor next to R1s commode, picked it up, and placed it on the spoon to give to R1.

During S7s interview, it was stated that the medication did not totally drop on the floor and dropped on the pants R1 was wearing. Another staff member (S6) confirmed that S7 did drop the resident’s medication and administered to the resident. In S6s interview of S7, confirmed to drop the medication, cleaned it, and gave it to R1. S6 states S7 put hand sanitizer prior to entering the room but did not perform hand hygiene inside the room prior to giving medication, then performed hand hygiene outside the room.

LPA Dolores also interviewed other staff members. S1 mentioned that if a medication drops, they pick it up, report it to Health Services Director (HSD), and pop another one if it's from the bubble pack, give the clean medication to the resident, then inform the pharmacy for another tablet because they would be missing supply. They're not supposed to give it to the resident because it's dirty. Another staff member (S3) also stated that if meds spill, S3 picks it up and disposed the med in the waste bin. They'd administer new medication by popping a new one. They do not give the medication that dropped to the resident. If they pop another one, they'd inform the pharmacy, and they would send a new one.

Therefore, based on interviews and 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 copy of this report and the Appeal Rights are provided.

page 2 of 2
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20220518114814
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: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/13/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Licensee to submit proof of in-service training regarding infection protocols. Licensee to submit by POC due date.
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This was not met as evidenced by: Based on records review, S2 was only wearing mask and no other PPEs while serving food to covid residents, S5 was not wearing mask while speaking to covid residents, which poses an immediate health, safety or personal rights risk to persons in care.
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Request Denied
Type A
09/13/2024
Section Cited
CCR
87411(a)
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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 ...
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Licensee to submit proof of in-service training regarding medication administration. Licensee to submit by
POC due date.
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This was not met as evidenced by: Based on records review & interviews, S6 administered medication that has already fallen on the floor, which poses an immediate health, safety or personal rights risk to persons in care.
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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 JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
05/18/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220518114814

FACILITY NAME:OAKMONT OF SAN JOSEFACILITY NUMBER:
435202818
ADMINISTRATOR:SILVA, FLAVIOFACILITY TYPE:
740
ADDRESS:917 THORNTON WAYTELEPHONE:
(408) 371-7100
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:92CENSUS: 82DATE:
09/06/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Sherry TheamTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are providing care and supervision while being ill
Staff are not performing hand hygiene when assisting with medications
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/6/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Memory Care Director Sherry Theam and explained the purpose of today's visit.

Regarding the allegation of staff are providing care and supervision while being ill, RP observed staff member (S4) to have the sniffles and congestion while working and caring for residents, but it has cleared up. S4told RP that it was allergies. On 05/17/2022, RP observed S4 to have the sniffles while working. RP also observed staff member (S8) to sound sick while working. S8 works the NOC shift and was wearing a mask.

LPA was able to interview S4 and stated that, he/she never comes to work with symptoms, only when he/she got vaccinated and called out. S4 has allergies and recently has been sneezing a lot.

page 1 of 2

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
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 7
Control Number 26-AS-20220518114814
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: 09/06/2024
NARRATIVE
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LPA has reminded RP that per HIPAA law, we are not able to disclose if a resident or staff have covid and that the facility is being monitored during this time.

Regarding the allegation staff are not performing hand hygiene when assisting with medications, RP stated that staff member (S7) failing to sanitize her hands, or put on gloves, while administering medication R1. S2 entered the room and did not wash or sanitize his/her hands prior to touching the rim of R1s water cup. S7s fingers are touching the rim of the cup where R1 will be placing his/her lips as he/she drinks. S7 did not put on gloves either.

LPA Dolores was able to interview S7 and it was stated that S7 would use hand sanitizer outside the room. S7 would enter the room and give the resident medication. LPA Dolores asked S7 if he/she would perform hand hygiene prior to administering the resident's medications and S7 states to already put on hand sanitizer outside the room.

Based on records review, according to Title 22 regulation, 87470 Infection Control Requirements (a)(1)(A) Hand hygiene shall include hand washing with soap and water or using an alcohol based sanitizer or any other sanitizing method recommended by a medical professional, local health official, health department, or other research based medical authority.

Based on interviews & records review, 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.

page 2 of 2
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
05/18/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220518114814

FACILITY NAME:OAKMONT OF SAN JOSEFACILITY NUMBER:
435202818
ADMINISTRATOR:SILVA, FLAVIOFACILITY TYPE:
740
ADDRESS:917 THORNTON WAYTELEPHONE:
(408) 371-7100
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:92CENSUS: 82DATE:
09/06/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Sherry TheamTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
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8
9
Administrator is not disclosing COVID-19 cases truthfully to family members
INVESTIGATION FINDINGS:
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On 9/6/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Memory Care Director Sherry Theam and explained the purpose of today's visit.

Regarding the allegation that administrator is not disclosing COVID-19 cases truthfully to family members, RP mentioned that the letter states there is a COVID “case” but there are multiple cases in the facilities. RP states this is misleading information to the family members.

LPA was able to obtain the letter, it does say “COVID case”, however at the bottom of the letter it also states “If you have any questions, comments, or concerns, please contact me,” so this way if there are any clarifications, responsible parties are able to confirm with the administrator.

page 1 of 2
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20220518114814
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: 09/06/2024
NARRATIVE
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Based also on records review, according to PIN 20-13- ASC Notification To Families When A Person Tests Positive For Coronavirus Disease 2019 (Covid-19) , Upon confirmation that a person in care or facility staff member has tested positive for COVID-19, and either remains in the facility or is no longer in the facility, CCLD advises ASC licensees to provide immediate notice to families of all persons in care. The notice to all families shall not disclose any personally identifiable information or protected health information about the person who tested positive for COVID-19.

Based on interviews and records review, the department has determined that that the allegation 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 JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7