435202818-6-9-2023-26-AS-KHOS-CSYKND-20230620080258

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202818
Report Date: 06/09/2023
Date Signed: 06/09/2023 05:13:18 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
06/01/2023 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20230601152026

FACILITY NAME:	OAKMONT OF SAN JOSE		FACILITY NUMBER:	435202818
ADMINISTRATOR:	SAN SOR		FACILITY TYPE:	740
ADDRESS:	917 THORNTON WAY		TELEPHONE:	(408) 371-7100
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	92	CENSUS: 63	DATE:	06/09/2023
		UNANNOUNCED	TIME BEGAN:	01:47 PM
MET WITH:			TIME COMPLETED:	05:16 PM

ALLEGATION(S):

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Staff did not respond to residents call button

INVESTIGATION FINDINGS:

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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced complaint investigation regarding the above allegation. LPA met with facility Administrator San Sor (Admin).

During the course of the investigation, LPA entered a resident room within the memory care wing of the facility and pressed the alarm button in the resident's bathroom. LPA waited at the resident room for 15 minutes, but no facility staff responded to the call. LPA met with Memory Care Director Sherry Tham (MCD) and informed her that no caregivers responded to the call. MCD confirmed that a notification for LPA pressing the alarm did appear within the central database.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

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-20230601152026

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: 06/09/2023

NARRATIVE

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Care giving staff was assembled in the activities room. There were currently 3 caregivers working in the memory care wing. 1 caregiver did not have a pager, 1 caregiver had a pager that was not functioning properly, and 1 caregiver received the alert, but was busy assisting another resident.

LPA reviewed the facility call logs from 06/02/2023 to 06/09/2023. During this period, there were 116 instances in which calls went out from resident pendant alarms or push alarms located within facility rooms that were recorded as not responded to in the facility reports. Facility call logs indicate that these calls required a response but never received one.

The Department has conducted an investigation of the above allegations. Based on LPA's observations, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiency cited. See LIC 9099-D. Exit interview conducted with Administrator San Sor. A copy of this report, along with the facility's appeals rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
06/01/2023 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20230601152026

FACILITY NAME:	OAKMONT OF SAN JOSE		FACILITY NUMBER:	435202818
ADMINISTRATOR:	SAN SOR		FACILITY TYPE:	740
ADDRESS:	917 THORNTON WAY		TELEPHONE:	(408) 371-7100
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	92	CENSUS: 63	DATE:	06/09/2023
		UNANNOUNCED	TIME BEGAN:	01:47 PM
MET WITH:	San Sor		TIME COMPLETED:	05:16 PM

ALLEGATION(S):

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Staff did not immediately provide resident's authorized representative with facilities policies and procedures

INVESTIGATION FINDINGS:

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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced complaint investigation regarding the above allegation. LPA met with facility administrator San Sor (Admin).

During the course of the investigation, LPA determined that there was only one resident (R1) currently at the facility experiencing alleged issues with provision of documents to autorhized representatives. LPA reviewed the power of attorney agreement for R1. LPA determined the identity of the POA and interviewed the individual listed (W1). In an interview with W1, W1 stated that the facility has never withheld or refused to provide documents upon request. W1 stated that the facility has always been prompt when alerting them to changes in R1's condition and promptly delivers all care updates. Continued in 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20230601152026

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: 06/09/2023

NARRATIVE

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Review of facility email correspondence with family members of residents indicate that the facility delivered permissible requested documents to requesting parties within an appropriate time frame.

This Department has investigated the above allegation. Based on interviews conducted, and records reviewed, the Department has found that this allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

Exit interview conducted with licensee/administrator. A copy of this report was provided for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20230601152026

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: 06/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/16/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 - Personnel Records - (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to provide in-service training to facility staff to retrain staff on how to respond to resident pendant and alarm calls. Facility to begin daily monitoring of call logs to check response times and provide POC by due date.
	8 9 10 11 12 13 14	Based on LPA observation and records review, facility staff did not responded to calls for assistence from resident call pendants and alarms. This poses a potential threat to the health and safety of residents 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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

LIC9099 (FAS) - (06/04)

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