435202447-10-30-2025-26-AS-MPAA-DMY7GK-20251030213916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 10/30/2025
Date Signed: 10/30/2025 09:41:50 PM

Document Has Been Signed on 10/30/2025 09:41 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 JOSE		FACILITY NUMBER:	435202447
ADMINISTRATOR/ DIRECTOR:	DONNER, ZEINAB		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY: 153		CENSUS: 97	DATE:	10/30/2025
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:00 PM
MET WITH:	Zeinab Donner		TIME VISIT/ INSPECTION COMPLETED:	05:30 PM

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	Licensing Program Analyst (LPA) Mita Partoza conducted announced pre-licensing visit for a change of ownership. LPA met with Zeinab Donner current Executive Director (ED/ADM). The facility is transitioning to a new owner and will have a new DBA name Marbella San Jose. The facility is sectioned into three parts, assisted living, memory care and independent living. The independent living portion of the community is not licensed by CCLD. However the Assisted Living and Memory Care area are licensed under CCLD. This facility is not a Continuing Care Residential Community (CCRC). The facility is a residential care facility for the elderly (RCFE). Assisted Living has 61 rooms and Memory Care has 28 rooms. LPA inspected the Memory Care area and Assisted Living Area. LPA toured the facility inside and outside, assisted living area, memory care unit, dining area, library, activity area, 3 kitchen including the main kitchen that prepares the meals for the entire community (assisted living, memory care and independent living). LPA observed interior & exterior walkways are free from obstructions and tripping hazards. Delayed egress was observed in the memory care unit and a keypad to enter is required. No bodies of water was observed. “Oxygen in Use/No smoking” signs were observed posted outside the residents’ room where oxygen was administered. Exit route maps were observed and strategically placed in each floor hallways. page 2

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 10/30/2025

NARRATIVE

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LPA inspected activity areas, library, media room, theater room, exercise room, and other commons areas and observed residents actively engaged in recreational programs and activities. Activity calendar was observed posted at different parts of the facility. LPA inspected laundry rooms on each floor and observed working washer and dryer units. Sharp objects, detergents, and chemicals were observed to be locked and inaccessible to persons in memory care. LPA observed locked centrally stored medication carts in the Assisted Living and Memory Care units. LPA observed nurse's station located in each floor of the assisted living area. LPA observed resident rooms at memory care and assisted living to be maintained and sanitary.
Bathrooms are equipped with grab bars and non-skid mats. Water temperature is checked each week and logged by maintenance supervisor.

LPA inspected the main kitchen and observed the kitchen to be organized and sanitary. The freezer and refrigerators are maintained at 0 degree F, the refrigerator is maintained at 32 degree F and checked temperature is log 5 times a day. LPA observed two (2) days perishable food able to sustain the entire community and nonperishable food for seven (7) days. The dining rooms in Assisted Living and Memory Care were observed to be sanitary and maintained.

LPA inspected observed fire extinguishers to be strategically placed in each floor and area of the Assisted Living and Memory Care that was recently inspected 10/13/2025. ED stated SSS Fire Protection Inc maintains their Automatic sprinkler systems quarterly and was checked last by SSS on 10/13/2025.
Fire Detection Unlimited (FDU) maintains the smoke alarm and carbon monoxide semi-annually and last inspection made was on 08/27/2025.

No deficiencies were found during inspection. An exit interview was conducted Zeinab Donner, Executive Director/Administrator and a copy of this report was provided.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025

LIC809 (FAS) - (06/04)

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