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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 03/25/2021
Date Signed: 03/25/2021 05:23:28 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:ODETTE COLONDRES TORRESFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:153CENSUS: 75DATE:
03/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Marie HarrisTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a Case Management tele-visit today and met with Executive Director (ED) Marie Harris. Due to COVID-19 restrictions, facility visits have been suspended.

The purpose of this Case Management was to address deficiencies identified during a complaint investigation involving resident (R1).

Complaint 26-AS-20201106171220 alleged that R1 had personal property removed from R1's room without permission. LPA request facility records including R1's Admission Agreement and personal property inventory. The investigation revealed R1 does not have an inventory of personal property upon admission as stated in the facility's Theft and Loss Policy. Records reviewed did not show R1 declined to inventory R1's personal property.

A deficiency is being cited today. See LIC 809-D. Appeal Rights were provided.

This report was discussed with ED and a copy 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: 03/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/02/2021
Section Cited

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87218 THEFT AND LOSS.
(a)(1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative. This requirement was not met as evidenced by:
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Based on review of facility records, R1 did not have an initial inventory of personal property upon admission to the facility. Records showed R1 did not decline to inventory personal property. This posed a potential risk to R1's personal rights.
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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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2021
LIC809 (FAS) - (06/04)
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