435202447-4-17-2025-26-AS-KHOS-DGTKPT-20250519080516

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 04/17/2025
Date Signed: 04/17/2025 02:58:50 PM

Unsubstantiated

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
04/09/2025 and conducted by Evaluator Christine Kabariti

COMPLAINT CONTROL NUMBER: 26-AS-20250409102834

FACILITY NAME:	BROOKDALE SAN JOSE		FACILITY NUMBER:	435202447
ADMINISTRATOR:	RYAN GOLZE		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	153	CENSUS: 72	DATE:	04/17/2025
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Banu Grewall and Sabrina Setz		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Facility staff yelled at a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to open the initial complaint investigation. LPA met with Health and Wellness Director, Banu Grewall and Assisted Living Director, Sabrina Setz.

On 04/09/2025, the Department received the complaint. On 04/17/2025, the initial complaint investigation was conducted. Documents were obtained to include the staff schedule, staff roster, resident roster and 5 resident files: physician's report, needs and services plan, and progress notes.

It was alleged that on 04/06/2025 during breakfast, a resident (R1) was yelled at by facility staff (S1) while in the presence of other residents having breakfast. See LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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-20250409102834

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: BROOKDALE SAN JOSE	FACILITY NUMBER: 435202447
	VISIT DATE: 04/17/2025

NARRATIVE

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8 staff members were interviewed. Based on staff interview, staff (S1) was not working in the facility the morning of 04/06/2025. The review of record shows that S1 was off on 04/06/2025.

Based on interviews, it was stated that R1 also accused staff (S2) yelling at R1 during breakfast time in the dining room.

8 out of 8 staff interviewed denied any staff yelling at residents to include R1. It was stated that during breakfast time on 04/06/2025, R1 was very agitated and was yelling at the staff and another resident. It was stated that the staff involved did not yell or raise their voice towards the resident and spoke to R1 politely.

5 residents were interviewed. Based on resident interview, R1 felt very upset towards certain staff members at the facility. R1 denied being spoken inappropriately to by S1. 4 out of 5 residents denied the observation of staff yelling at a resident in the dining room area during breakfast time. Residents who were in the dining room during the incident denied the observation of S2 yelling at R1.

The review of record shows that on 04/07/2025, 2 staff members spoke with R1 regarding R1’s behavior towards the staff and residents. It was stated that R1 was angry and upset about another resident's services.

They Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Health and Wellness Director, Banu Grewall and Assisted Living Director, Sabrina Setz and a copy of the report was provided.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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