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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 09/11/2020
Date Signed: 09/11/2020 04:05:01 PM

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: 125DATE:
09/11/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Antonette EdwardsTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an unannounced Case Management tele-visit today and met with Assisted Living Director (ALD) Antonette Edwards.

The purpose of this case management was to obtain more information regarding a report received by Community Care Licensing Division (CCLD) from resident, R1.

LPA interviewed the facility's Independent Living Resident Services Director (IL-RSD), Lisa Martinez who confirmed that R1 is a resident in their Independent Living unit. ALD also confirmed that R1 is not a resident of their Assisted Living or Memory Care unit.

Based on interviews, R1's family has been notified and the facility had conducted an investigation. R1 also retracted the report against an independent contractor for cable TV entering R1's bedroom and making R1 sit on his lap. R1 will be assessed further after R1 stated R1 was confused.

Per IL-RSD, the alleged independent contractor is not an employee of the facility and does not do work for the Assisted Living or Memory Care unit.

No deficiency was cited. A copy of this report was provided to ALD Antonette Edwards by email.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2020
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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