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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202447
Report Date:
05/06/2021
Date Signed:
05/06/2021 02:33:18 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 JOSE
FACILITY NUMBER:
435202447
ADMINISTRATOR:
MARIE HARRIS
FACILITY TYPE:
740
ADDRESS:
1009 BLOSSOM RIVER WAY
TELEPHONE:
(408) 445-7770
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95123
CAPACITY:
153
CENSUS:
89
DATE:
05/06/2021
TYPE OF VISIT:
Case Management - Other
ANNOUNCED
TIME BEGAN:
10:30 AM
MET WITH:
Marie Harris
TIME COMPLETED:
11:00 AM
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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 and Health and Wellness Director (HWD) Harriette Vega via video conferencing due to COVID-19 preventive measures.
A review of the facility's current resident roster and staffing schedule for both Assisted Living and Memory Care was conducted.
LPA reviewed and discussed the facility's program plan regarding work shifts and medications policies and procedures based on documents submitted to the Department during the license application process.
LPA was informed by ED and HWD of a medications audit scheduled next week. Results will be shared with LPA.
No deficiencies were cited today. Exit interview conducted and a copy of this report provided electronically to ED for signature.
SUPERVISOR'S NAME:
Sarah Yip
TELEPHONE:
(408) 324-2131
LICENSING EVALUATOR NAME:
Gladys Kuizon
TELEPHONE:
(408) 834-2558
LICENSING EVALUATOR SIGNATURE:
DATE:
05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/06/2021
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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