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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 03/10/2021
Date Signed: 03/16/2021 10:48:16 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:ODETTE COLONDRES TORRESFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:153CENSUS: 75DATE:
03/10/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Marie Harris - Executive DirectorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a Case Management - Legal/Non-compliance inspection visit to ensure that facility is adhering to the Compliance Plan submitted to Community Care Licensing Division (CCLD) after a Non-Compliance Conference held on 11/14/2018. Due to COVID-19 restrictions, LPA met with Executive Director Marie Harris via video conferencing. Also present during the meeting were Assisted Living Director Rizaldy Carreon and Health and Wellness Director Harriette Vega.

At 11:44 AM, a virtual tour of the facility was conducted. The facility's main kitchen and food storage were inspected. Perishable and non-perishable foods were observed labeled and stored in a safe and healthful manner. Assisted Living kitchens on the 1st and 2nd floors were also inspected and observed consistent with the facility's food labelling and storage procedures.

At 12:06 PM, the facility's pendant alert system was tested from the Assisted Living unit. Staff responded within 1 minute. Resident confirmed that staff usually responds within 10 minutes.

At 12:17 PM, the facility's Memory Care unit was toured. 7 residents were observed in the dining room. 2 dining staff and 2 caregivers were observed with residents. The delayed egress door alarms were tested and observed in good working condition.

Staff training records were reviewed and observed in compliance with the facility's compliance plan.

Based on LPA's review of the facility inspection visits from 2018 - 2020 and observations on this visit, the two (2) year quarterly case management visits imposed on the facility on November 14, 2018 concludes today

Continued, see LIC 809-C, page 2 of 2.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 JOSE
FACILITY NUMBER: 435202447
VISIT DATE: 03/10/2021
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Facility shall stay updated with Provider Information Notices and Title 22 regulations to ensure compliance at all times.

Exit interview conducted with Executive Director. A copy of this report was provided electronically for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2021
LIC809 (FAS) - (06/04)
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