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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 07/28/2020
Date Signed: 07/29/2020 09:47:43 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BROOKDALE SAN JOSEFACILITY NUMBER:
435202447
ADMINISTRATOR:MICHELE MERRITTFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:153CENSUS: 92DATE:
07/28/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:46 PM
MET WITH:Antonette EdwardsTIME COMPLETED:
03:58 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced case management - incident tele-visit. Due to current COVID-19 situation, LPA virtually met with Assisted Living Director (ALD) Antonette Edwards via phone.

On 7/21/2020, the Department received a report stating a resident (R1) showed inappropriate behavior towards staff in the facility. However, there was no physical altercation or injury on other residents.

ALD stated that the facility was aware of R1's behavior. Executive Director (ED) Michele Merritt and ALD would set up a meeting with R1 to discuss R1's behavior and house rules. A special arrangement was made to continue providing service to R1 at this moment.

No deficiency cited during tele-visit. This case management - incident remained open pending additional report.

This report was emailed to ALD to review and to sign.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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