430702959-7-16-2024-26-AS-JJIN-D7FU3F-20240723151328

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430702959
Report Date: 07/16/2024
Date Signed: 07/16/2024 12:32:21 PM

Unfounded

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
03/15/2023 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230315144631

FACILITY NAME:	JULIET STEPHEN REST HOME		FACILITY NUMBER:	430702959
ADMINISTRATOR:	OLIVA, DOMINICA		FACILITY TYPE:	740
ADDRESS:	909 COLLEGE DRIVE		TELEPHONE:	(408) 298-9502
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	6	CENSUS: 6	DATE:	07/16/2024
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Dominica Oliva		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident sustained multiple other injuries while in care.
Facility staff are not following resident's care plan.
Facility staff are not assisting resident with toileting.
Facility staff are not meeting resident's hygiene needs.
Facility staff are not ensuring that resident is adequately/ nutritionally fed.
Facility staff are not ensuring that resident is changed into clean clothing.
Facility staff took away resident's call light.

INVESTIGATION FINDINGS:

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On 7/16/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Dominica Oliva and explained the purpose of today's visit.

Regarding the allegation of resident R1 sustained multiple other injuries while in care, Reporting Party (RP) stated that R1 has a lot of tears on his arms and a bruise on his eye. RP stated that he/she always sees client with new bruises and bandages.

According to an interview with a staff member (S3), R1 did sustain bruising to the arms due to R1 pulling the call cord and the curtains. Staff has since placed pillows and requested foam padding to place around the window to prevent further injuries. A responsible party (F1) was also interviewed and stated that he/she has asked hospital staff if they could assess R1 for abuse or neglect. Hospital staff told F1 that R1 was well taken care of and believed that the facility was providing the appropriate level of care that R1 needs. Home Health Nurse (RN) also did not believe that R1 was abused or neglected in any way while residing in the facility.

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230315144631

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: JULIET STEPHEN REST HOME	FACILITY NUMBER: 430702959
	VISIT DATE: 07/16/2024

NARRATIVE

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LPA Dolores observed that there are no bruises on R1s eyes. Skin was observed clean (hands and face). No visible band-aid observed.

Regarding the allegation of facility staff are not following resident's care plan, RP stated that R1s brace legs are too tight that the legs are swollen due to poor circulation. R1s legs are contracted because staff are not exercising R1.

Based on interviews, RN mentioned that the staff were told to follow the wound care clinic’s orders which was taught to them. RN also had staff demonstrate what was taught to them to gauge their understanding of what to do. Another LVN mentioned that R1 has braces and and staff were advised not to remove this. A staff member (S1) mentioned that the RP removed the foot cap to give air out to the foot. The nurse even said don’t remove it but still removed it. Another staff (S4) stated that home health nurses as well as the wound care clinic nurses and doctors instructed staff to elevate R1’s heels and use booties. Staff were also instructed initially not to touch or change the wound dressing. After three weeks or so, staff were instructed to clean the wound daily with saline, then apply an ointment and rebandage the wound until R1s next appointment.

Regarding the allegations of facility staff are not assisting resident with toileting, facility staff are not meeting resident's hygiene needs & facility staff are not ensuring that resident is changed into clean clothing. RP stated that R1 is not being allowed to pivot to bedside commode, has not been bathed since moving into this facility, R1’s clothes that are soiled with food is not being changed, RP has seen R1 with the same clothes for 3 days.

LPA Dolores was able to interview three residents and Investigation Bureau (IB) was able to interview a resident. Three of these residents stated that they didn’t have issues with the care in the facility. A resident (R1) stated that staff help her, they help R1 with shower, change clothes & change diapers. Another resident (R2) mentioned that staff helps with grooming, showering, transferring, assisting with meals. R4 mentioned that he/she is unable to turn and staff roll him/her to the side to change diaper.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20230315144631

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: JULIET STEPHEN REST HOME	FACILITY NUMBER: 430702959
	VISIT DATE: 07/16/2024

NARRATIVE

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IB also interviewed a staff member (S3) and mentioned that he/she helped clean R1. S3 checks on residents every 2-3 hours to see if they are still in bed, change their diapers and gives them a daily bath or a shower. Another staff member (S2) stated that job duties and responsibilities includes cleaning the residents, assisting them with their needs, washing their clothes, assisting to eat, checking on them every 2 hours and every minute, showering, changing their clothes, and helping each other. S1 also shared that they assist R1 to the commode. There are times they gave R1 diapers but more often they bring R1 to the commode or bathroom. R1 stayed in the last room, the bathroom was very close.

LPA Dolores also observed that R1 was wearing a grey long sleeve with blue plaid pajama pants. R1's clothing was not observed to be dirty with obvious stains or dirt. No foul odor observed. R1's hair was not combed. There was 2 brown crumbs of food that was very small on R1's beard. R1 had a table tray in front of him with a snack and water.

Regarding the allegation of facility staff are not ensuring that resident is adequately/ nutritionally fed, RP stated that RP has seen R1 being fed cookies and peanuts and rarely has RP seen client being fed a full meal.

During the interviews, R2 stated that they had breakfast and lunch but could not recall if they ate dinner. R3 stated that they give 3 meals. R4 mentioned that living here is good. They give 3 meals a day and snacks. S1 also mentioned that they were feeding R1 the regular food. 3 meals a day.

Regarding the allegation that facility staff took away resident's call light, RP stated that staff took R1s call light away months ago because R1 calls too much.

According to interviews, S1 mentioned that R1 pulls the call light and at one time R1 pulls it and they have to put it back. R1 pulls himself up with the call light. So many timed R1 yanked it. No one took it away from him. There wasn’t a problem with the call light.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20230315144631

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: JULIET STEPHEN REST HOME	FACILITY NUMBER: 430702959
	VISIT DATE: 07/16/2024

NARRATIVE

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LPA Dolores observed during a visit that R1s call cord was disconnected. LPA observed the call cord was placed on top of the dresser where R1's TV is located. S3 stated they removed the call cord because R1 kept pulling the cord for no reason. They have staff who check in on the R1 multiple times every hour of the day to ensure R1 is okay. S3 re-connected the call cord during visit. S3 pressed the call cord and LPA observed the call cord was operable.

Based on interviews and observations, 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.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC9099 (FAS) - (06/04)

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