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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 02/09/2024
Date Signed: 02/09/2024 05:42:45 PM

Document Has Been Signed on 02/09/2024 05:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 JOSEFACILITY NUMBER:
435202447
ADMINISTRATOR:RYAN GOLZEFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 153CENSUS: 71DATE:
02/09/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Zeinab DonnerTIME COMPLETED:
05:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the annual continuation. LPA met with Executive Director (ED) Zeinab Donner.

LPA entered the Memory Care unit with ED. Memory care is equipped with delayed egress doors. During visit, LPA observed residents participating in activities. Activities calendar observed posted in the hallway. Temperature maintained at 72 degrees Fahrenheit. LPA and ED entered into 5 resident bedrooms. LPA observed the bedrooms were equipped with adequate lighting, beds, linens, dressers, chairs, and night stands. LPA did not observe any items that could pose a danger to residents with Dementia accessible to residents. Resident bathrooms observed with non-slid floors in the shower and grab bars. Hot water temperature in the resident bathrooms of room C2, C3, and C21 maintained at 105 degrees Fahrenheit.

LPA entered the Assisted Living section with ED. LPA entered into room 244 and 229. Water temperature for both rooms maintained at 100 degrees Fahrenheit.

LPA reviewed 3 resident files in memory care. 2 out of 3 residents who are diagnosed with Dementia did not have an updated medical assessment. R1's medical assessment was last updated in 2021 and R2's medical assessment was last updated in 2022. 3 out of 3 residents files does not contain an signed and dated appraisal/needs and services plan. 3 out of 3 residents files contained a signed admission agreement, consent form, personal rights, safeguard of personal properties and valuables, TB result, and emergency/identification form. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: BROOKDALE SAN JOSE
FACILITY NUMBER: 435202447
VISIT DATE: 02/09/2024
NARRATIVE
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 LPA reviewed 3 residents centrally stored medications and centrally stored medication records. Two of R1's medications were not written in the centrally stored medication records. One of R2's medication was expired as of 10/2023, R2 was last given the medication in July 2023.

LPA reviewed 5 resident files in assisted living. 1 out of 5 resident (R3) file did not contain a TB result. 1 out of 5 resident (R4) file did not contain a consent for medical treatment, signed personal rights form, and safeguard of personal properties form. 5 out of 5 residents does not contain a signed and dated appraisal/needs and services plan. 5 out of 5 residents files contained a signed admission agreement. 3 out of 5 residents are under medication management. 3 out of 5 residents centrally stored medications and centrally stored medication records were observed maintained.

On 01/31/2024, LPA Dolores reviewed 6 staff files (S1 - S6). 5 out of 6 staff members does not have an active first aid certification. LPA observed the ED has an active first aid certification. LPA did not observed any NOC shift staff contains an active first aid certification. LPA reviewed 6 out of 6 staff annual training records.

LPA observed the facility's emergency food supply was replenished and re-organized.

LPA interviewed 5 staff members and 6 residents.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Executive Director (ED) Zeinab Donner and a copy of the report and appeal rights will be provided. \
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 02/09/2024 05:42 PM - It Cannot Be Edited


Created By: Christine Dolores On 02/09/2024 at 05:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation, interview, and record review the licensee did not ensure resident (R3) had a TB test and/or TB result prior to residing in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2024
Plan of Correction
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Licensee will get R3 tested for TB by tomorrow, 02/10/2024. Licensee will audit the rest of the residents records. Licensee will send
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not ensure the 2nd floor water temperature was maintained at least 105 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2024
Plan of Correction
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Licensee will submit a plan in place on how they're going to audit and test the water temperature going forward. Licensee will submit the plan in writing via email to LPA Dolores by POC due date.
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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 02/09/2024 05:42 PM - It Cannot Be Edited


Created By: Christine Dolores On 02/09/2024 at 05:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not ensure at least one NOC shift staff member contained an active first aid/CPR ceritification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee will submit a written plan to ensure at least one staff member per shift obtains a first aid/CPR certification to LPA Dolores via email by POC due date.
Type B
Section Cited
CCR
87705(c)(5)
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review 2 out of 3 residents diagnosed with dementia did not have an annual medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee will submit a written plan in writing to ensure all staff who are diagnosed with dementia will have an annual medication assessment on file to LPA Dolores via email by POC due date.
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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 02/09/2024 05:42 PM - It Cannot Be Edited


Created By: Christine Dolores On 02/09/2024 at 05:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not ensure to obtain a signature and date from the resident and/or resident's representative for 8 residents appraisal/needs and services plan, and maintain 2 resident's centrally stored medication records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee will reach out to the 8 resident families to get a signed and dated appraisal/needs and services plan. Licensee will send LPA Dolores 8 residents signed appraisal/needs and services plan via email by POC due date. Licensee will provide an in-service training regarding centrally stored medications. Licensee will send the in-service training document to LPA Dolores via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
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