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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 04/14/2022
Date Signed: 04/14/2022 04:20:21 PM


Document Has Been Signed on 04/14/2022 04:20 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
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: 80DATE:
04/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marie HarrisTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Steve Chang, and Licensing Program Manager (LPM) Sarah Yip conducted Technical Assistant through tele-inspection (Zoom), and met with Administrator (ADM) Marie Harris.

The purpose of this Technical Assistance (TA) Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. It was observed that the facility did not have COVID signage on the main door. ADM stated the facility will put the signage on later. Facility has a screening station with infection control questionnaires, visit and staff log book, thermometer, and hand sanitizers. Facility staff showed and read the infection control questionnaires to LPA/LPM.

LPA/LPM toured the common area with ADM including the common restroom and dinning hall. It was observed no washing hands for 20 seconds signage by the sink in the restroom. ADM stated the facility will put the signage on later. Paper towels with dispenser and trash can with cover were observed in the restroom. Dinning hall was inspected.

LPA/LPM toured the isolation room with ADM. PPE station was observed outside the isolation room. It was observed that there was no donning and doffing PPE signage posted outside the isolation room. ADM stated the facility will post the donning and doffing PPE signages inside and outside the isolation room.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: BROOKDALE SAN JOSE
FACILITY NUMBER: 435202447
VISIT DATE: 04/14/2022
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Based on today's inspection, the facility is being recommended the following:

1. Facility to post more COVID signage on the facility main door and inside the facility.
2. Facility to post washing hands for 20 seconds signage in restrooms.
3. Facility to disinfect high touch areas more often.
4. Facility to post the sequence of donning and doffing PPE signage inside and outside the
isolation room.
5. Facility to conduct staff training at least monthly or frequently such as donning and
doffing PPE and COVID -19 updates by CDC, local public health and to review
DSS-CCLD (Providers Information Notice-PINS). CCLD website: www.ccld.ca.gov.
6. LPA provided COVID-19 resource to Licensee.

No deficiencies cited during today's Tele Visit. Exit interview conducted with ADM.
A copy of this report emailed to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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