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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 05/02/2025
Date Signed: 05/02/2025 04:03:34 PM

Unfounded


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
06/09/2022 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20220609103627
FACILITY NAME:BROOKDALE SAN JOSEFACILITY NUMBER:
435202447
ADMINISTRATOR:MARIE HARRISFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:153CENSUS: 96DATE:
05/02/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director Zeinab DonnerTIME COMPLETED:
04:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not follow proper protocol for COVID-19
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Executive Director Zeinab Donner

On June 9, 2022, the Department received a complaint alleging Facility did not follow proper protocol for COVID-19.

On June 14, 2022, LPA Marrufo interviewed witness W1. W1 stated covid positive residents with neurocognitive disorder, walk in and out, around other residents. W1 stated residents who are not covid positive are wandering inside rooms with covid positive residents.

On June 17, 2022, LPA David Marrufo conducted an initial investigation.
Page 1 Out of 2.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 26-AS-20220609103627
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: 05/02/2025
NARRATIVE
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On May 2, 2025, LPA Monter interviewed residents R1-R13. 10 Out of 13 (R1-R10) residents interviewed stated the facility follows infection control protocols for covid 19. 3 Out of 13 (R11-R13) declined to be interviewed.

LPA Monter interviewed staff S1-S10. 10 Out of 10 staff interviewed stated the facility follows infection control protocols, such as masking, isolating covid positive residents, and delivering meals to residents. 10 Out of 10 staff interviewed stated staff do not allow covid positive residents to wander into other residents bedrooms.

LPA Monter interviewed Executive Director (ED) Zeinab Donner stated they following the department of health guidelines and report it to CCL. Executive Director Zeinab Donner stated if a resident is covid positive, the resident will be isolated per public health guidelines. ED stated when staff interact with covid positive residents, the staff will wear PPE. ED stated they will also notify families. ED stated when it hits a certain percentage, then they will close dinning and activities.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
06/09/2022 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20220609103627

FACILITY NAME:BROOKDALE SAN JOSEFACILITY NUMBER:
435202447
ADMINISTRATOR:MARIE HARRISFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:153CENSUS: 96DATE:
05/02/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director Zeinab DonnerTIME COMPLETED:
04:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Insufficient staffing
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On June 9, 2022, the Department received a complaint alleging Insufficient staffing.

On June 14, 2022, LPA Marrufo interviewed witness W1. W1 stated staff don’t want to work in COVID area. W1 stated sometimes they have no show and no care giver staff come in. W1 stated some staff don’t show up anymore because some of the residents are so hard to work with.

On June 17, 2022, LPA David Marrufo conducted an initial investigation.

Page 1 Out of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20220609103627
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: 05/02/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On May 2, 2025, LPA Monter interviewed residents R1-R13. 8 Out of 13 (R1-R8) residents interviewed stated they there is enough staff to meet their needs; such as, but not limited to showers, medications, laundry and housekeeping. 3 Out of 13 (R11-R13) residents interviewed declined to be interviewed. 2 Out of 13 residents (R9 & R10) interviewed stated there have been times when the facility has been short staffed and he/she needs to wait for more than 30 minutes for staff to respond to pendants.

LPA Monter interviewed staff S1-S10. 2 Out of of 10 Staff (S1-S2) stated the facility there have been times when the facility was short staffed, and wasn't enough staff to assist the residents. 8 out of 10 Staff (S3-S10) stated there is enough staff to meet the needs of residents in the facility.

LPA Monter interviewed Executive Director Zeinab Donner, who stated the facility has enough staff to meet the needs of residents in care.

On May 2, 2025, LPA Manuel Monter toured the facility assisted living section of the facility and randomly toured the following bedrooms: 161, 244, 231, 229, 230, 243, 152, 163, 156. While touring these bedrooms, LPA Monter observed the bedrooms as clean, safe and sanitary.

LPA Monter toured all resident bedrooms in the memory care section of the facility: C1-C28. LPA Monter observed the bedrooms as clean, safe and sanitary.

LPA tested the staff's response time to pendant activations. LPA tested the pendant in room 244 and staff responded in 2 minutes. LPA also tested the pendant in room 231, with a response time of 1 minute, 48 seconds.

During the tour of the facility, LPA did not observe any resident unkempt, un-showered or in an unsanitary state.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.
Page 2 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4