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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202898
Report Date: 12/16/2024
Date Signed: 12/16/2024 03:53:05 PM

Unfounded


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
03/15/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240315163012
FACILITY NAME:OAKMONT OF SILVER CREEKFACILITY NUMBER:
435202898
ADMINISTRATOR:DIAL, JAMESFACILITY TYPE:
740
ADDRESS:3544 SAN FELIPE ROADTELEPHONE:
(669) 200-2443
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:148CENSUS: 74DATE:
12/16/2024
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Holly Suiter - Executive Director/AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not notify resident's authorized representative of incident in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint investigation to deliver the findings on the above allegations. LPA met with Holly Suiter - Executive Director/Administrator

On March 15, 2024, the Department received a complaint alleging Staff did not notify resident's authorized representative of incident in a timely manner.

On March 13, 2024, the Department received an incident report Regarding resident R1 and R2. The incident report states both residents reside in the memory care unit. Furthermore, on March 6, 2024, at approximately 9:45pm, R1 entered R2’s room and laid in R2’s bed. R2 was using a hospital bed at the time, and R1 laid in the bed not being utilized. R2 came out of his/her room and informed staff that R1 was in his/her room.
Page 1 Out of 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
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 6
Control Number 26-AS-20240315163012
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 SILVER CREEK
FACILITY NUMBER: 435202898
VISIT DATE: 12/16/2024
NARRATIVE
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On March 22, 2024, LPA Steve Chang interviewed ADM, James Dial. ADM stated on March 7, 2024, he spoke with R2’s authorized representative for 2 hours.

LPA Chang interviewed Staff S1. S1 stated Staff S4 called R2’s authorized representative, but no one picked up the phone and could not leave a message. S1 stated he/she spoke with R2’s authorized representative on March 7, 2024, at 3:00pm.

LPA Chang interviewed R2’s authorized representative. (AR). AR stated the facility notified him/her about the incident in question, the following day.

On November 27, 2024, LPA Manuel Monter interviewed staff S4. S4 stated he/she had called R2’s authorized representative on March 6, 2024, but no one answered. S4 stated she left a voicemail.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
03/15/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240315163012

FACILITY NAME:OAKMONT OF SILVER CREEKFACILITY NUMBER:
435202898
ADMINISTRATOR:DIAL, JAMESFACILITY TYPE:
740
ADDRESS:3544 SAN FELIPE ROADTELEPHONE:
(669) 200-2443
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:148CENSUS: 74DATE:
12/16/2024
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Holly Suiter - Executive Director/AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not prevent resident from engaging in inappropriate behaviors
INVESTIGATION FINDINGS:
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On March 15, 2024, the Department received a complaint alleging Staff did not prevent resident from engaging in inappropriate behaviors.

On March 13, 2024, the Department received an incident report Regarding resident R1 and R2. The incident report states both residents reside in the memory care unit. Furthermore, on March 6, 2024, at approximately 9:45pm, R1 entered R2’s room and laid in R2’s bed. R2 was using a hospital bed at the time, and R1 laid in the bed not being utilized. R2 came out of his/her room and informed staff that R1 was in his/her room.

On March 22, 2024, LPA Steve Chang interviewed Staff S1 and S2. Both staff interviewed stated on March 6, 2024, around 9:45pm, R2 came out from his/her room and told caregivers that R1 was sleeping in his/her room. S2 stated he/she and S3 went inside and redirected R1. S2 stated he/she asked R2 if R1 touched him/her, and R2 stated no.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
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 6
Control Number 26-AS-20240315163012
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 SILVER CREEK
FACILITY NUMBER: 435202898
VISIT DATE: 12/16/2024
NARRATIVE
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LPA Chang interviewed R1. R1 did not respond to LPA’s questions and was unable to provide answers to LPA’s questions.

On November 21, 2024, LPA Monter interviewed staff S5-S10. S5 S6 S7 S8 S9 S10 stated R1 has the behavior of trying to enter other residents’ bedrooms. S5 & S8 stated since R1 moved into the facility, he/she has had the behavior of attempting to enter residents’ bedrooms. S5 - S10 stated staff are supposed to redirect R1 if he/she is trying to enter another resident’s bedroom. S5 stated staff are supposed to lock resident bedroom doors to prevent other residents from entering their bedrooms.

On November 27, 2024, LPA Monter interview staff S2-S4. S2 – S4 stated R1 has the behavior of entering other residents’ bedrooms. S2 stated on March 5, 2024, he/she was in the activity area/hallway, filling out paperwork in the hallway with staff S3. S2 stated he/she was 5 feet away from R2’s bedroom. S2 stated he/she didn’t see R1 enter R2’s room.

S3 stated he/she doesn’t remember what had happened on March 5, 2024. S3 stated “when we don’t have eyes on R1, that is when he/she enters others bedrooms.”

S4 stated on March 5, 2024, he/she was in the med room doing his/her end of shift report. S4 stated a staff member had told him/her that he/she couldn’t find R1. S4 stated R1 was then found in R2’s bedroom.

On December 5 and 13, 2024, LPA Manuel Monter interviewed staff S1 and S11. Both staff interviewed stated R1 had the behavior of entering other residents’ bedroom. S1 and S2 stated it was one of his/her behaviors, which he/she had since he/she moved in. S1 and S2 stated staff are supposed to redirect R1 when he/she is trying to enter another residents bedroom.

A review of R1’s progress notes revealed multiple instances where R1 had entered or attempted to enter other residents’ bedrooms. From the day R1 had moved in, August 16, 2023, till March 6, 2024, R1 had 10 instances of entering another residents bedroom.

Based on a review of R1’s Physicians Report, dated August 4, 2023, R1 has a neurocognitive disorder. R1 is also confused and has wandering behavior.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20240315163012
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 SILVER CREEK
FACILITY NUMBER: 435202898
VISIT DATE: 12/16/2024
NARRATIVE
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Based on a review of R1’s individualized Service plan, dated November 29, 2023, R1 has dementia. Under need, the form states R1 wanders into apartment agitating other residents. The form also states the task description for this behavior is to closely observe and guide wandering & to Cue or redirect for safety.

Based on a review of a facility incident Report (IR), dated September 13, 2023, R1 was found in resident R3’s room. R3 stated R1 had punched him/her on the face. The IR stated that R3 did have an observable small cut on the inside of his/her upper lip.

The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Holly Suiter - Executive Director/Administrator. A signed copy of this report was provided along with appeal rights.

Page 3 Out of 3. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Citations on this Visit Report are Under Appeal!

Control Number 26-AS-20240315163012
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 SILVER CREEK
FACILITY NUMBER: 435202898
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
12/17/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by;
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ADM stated R1 now has a 1 on 1 care giver from an outside agency, hired by R1's family member. ADM stated she will send a letter of understanding regarding the regulation.
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Based on records reviewed & interviews conducted, R1’s has the behavior of entering others residents bedrooms. R1’s care plan states R1 needs to be redirected & wandering guided for his/her safety. R1 entered R2’s bedroom, & staff was informed by R2. This poses/posed a potential health, safety or personal rights risk to persons in care.
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 ADM stated the plan of correction will be sent by POC date, 12/17/2024.
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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.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
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