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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202818
Report Date: 01/17/2024
Date Signed: 01/17/2024 04:24:45 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
01/09/2024 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20240109114455
FACILITY NAME:OAKMONT OF SAN JOSEFACILITY NUMBER:
435202818
ADMINISTRATOR:PAULA SPANEKFACILITY TYPE:
740
ADDRESS:917 THORNTON WAYTELEPHONE:
(408) 371-7100
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:92CENSUS: 58DATE:
01/17/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Paula SpanekTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility did not report suspected abuse to appropriate agencies within reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived to the facility unannounced to open the initial complaint investigation. LPA met with Executive Director (ED), Paula Spanek.

On 01/09/2024, the Department received a complaint alleging that the facility did not report suspected abuse within 24 hours to the Department and appropriate agencies. On 01/17/2024, the initial complaint investigation was conducted.

The following documents were obtained from the facility to include SOC341s (Report of Suspected Dependent Adult/Elder Abuse) that was sent to the Department from November 2023 – January 2024 and email correspondences.

Based on record review, the Department received SOC341s from the facility on 11/27/2023, 12/07/2023, and 12/14/2023. SEE LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
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 3
Control Number 26-AS-20240109114455
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: 01/17/2024
NARRATIVE
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During visit on 01/17/2024, LPA Dolores was provided SOC341s that were completed on 11/27/2023, 12/06/2023, 12/06/2023, and 12/12/2023.

The review of records showed that on 12/02/2023, the facility’s directors were emailed concerns from R1’s responsible party alleging suspected rough handling from staff (S1) to resident (R1) to include unexplained bruises on R1’s arms. Based on interview with staff, the facility did not inform the local law enforcement within 24 hours. The Department also did not receive a report regarding the suspected abuse within the 24 hour reporting requirement.

Based on record review, the Department received one SOC341 on 12/07/2023 regarding a visit from the local law enforcement on 12/05/2023. Based on the report, the reason for the visit was to ensure a safety plan was created and followed through to limit the interactions with R1 and a care staff member who R1 did not feel comfortable receiving care from.

During visit on 01/17/2024, LPA was provided another SOC341 completed on 12/06/2023, which the Department did not receive. This report alleged that R1 was handled rough by a staff (S1) on 12/01/2023.

Based on interview, 1 out of 2 of the SOC341s that was completed on 12/06/2023 was not sent to the Licensing Department because it was a draft. It was stated that the contents of both reports were the same as the report the Department received. Based on observation, the details of both the SOC341s completed on 12/06/2023 contained different contents and information.

The Department has investigated the above allegation. Based on interview, record review, and observation the preponderance of evidence standard has been met, therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Executive Director, Paula Spanek and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20240109114455
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: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/18/2024
Section Cited
CCR
87211(c)
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(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement is not met as evidenced by:
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Licensee will review Title 22 regulation Section 87211 and submit a statement of understanding of the section cited. Licensee will also submit an in-service training with the facility director's regarding
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Based on interview, record review, and observation the licensee did not ensure to report suspected physical abuse of resident (R1) from staff (S1) on 12/02/2023 to the local law enforcement and to the licensing department within 24 hours which poses/posed an immediate health, safety, and personal rights risk to persons in care.
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reporting requirements to appropriate agencies. Licensee will submit both POCs to LPA Dolores by 01/18/2024.
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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: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC9099 (FAS) - (06/04)
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