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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 07/09/2021
Date Signed: 07/16/2021 10:26:34 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:MARIE HARRISFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:153CENSUS: 89DATE:
07/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Marie Harris and Rizaldy CarreonTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with Executive Director Marie Harris and Assisted Living Director Rizaldy Carreon.

At 9:06 AM, LPA entered the facility through the main entrance point and was screened by staff. At 9:36 AM, a tour of the facility's assisted living (AL) building was conducted with staff. Another screening area was observed by the AL building's entrance. COVID-19 postings were observed in the hallways and common areas. Staff were observed wearing face coverings.

Hand sanitizers, soap, and paper supplies were observed available. At least 30 days' supply of personal protective equipment (PPE) were available in the premises.

Per Administrator, the facility is currently accepting visitors inside the facility, including residents' bedrooms. The facility has reached at least 70% COVID-19 vaccination rate for residents and staff. Surveillance testing for staff is still conducted weekly.

The facility's weekly activity schedule was reviewed and included exercises, craft classes, games, and musical activities.

The facility's COVID-19 mitigation plan has been reviewed and is still in place.

No deficiencies were cited. Exit interview conducted with Administrator and a copy of this report was provided during visit.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
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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