435202447-2-4-2026-26-AS-CKAI-DS2UYV-20260310160033

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 02/04/2026
Date Signed: 02/04/2026 03:59:31 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/14/2025 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20250514114259

FACILITY NAME:	BROOKDALE SAN JOSE		FACILITY NUMBER:	435202447
ADMINISTRATOR:	RYAN GOLZE		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	0	CENSUS: 95	DATE:	02/04/2026
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Zeinab Donner		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff do not ensure facility is free from pests
Staff do not treat residents with respect
Due to lack of staff, staff do not assist residents in their morning activities of daily living

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator (ADM) Zeinab Donner. On 05/14/2025, the department received a complaint with the above allegations. On 05/19/2025, LPA Marrufo conducted an initial complaint investigation visit. On 02/03/2026, LPA Marrufo conducted an additional complaint investigation visit.

During visit on 05/19/2025, LPA Marrufo interviewed 2 staff and 11 residents.

During visit on 02/03/2026, LPA Marrufo interviewed 11 staff and ADM.

See LIC9099-C pages. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20250514114259

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/04/2026

NARRATIVE

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Allegation: Staff do not ensure facility is free from pests - Unsubstantiated

When the department received the complaint, it was alleged that the facility has cockroaches.

During visit on 05/19/2025, LPA Marrufo obtained a copy of pest control invoices dated 02/04/2025, 02/17/2025, 02/26/2025, 03/04/2025, 03/10-11/2025, 03/12/2025, 03/20/2025, 03/26/2025, 04/02/2025, 04/23/2025, 04/24/2025, and 05/13/2025. The services in the invoices include “Cockroach/Rodent program.”

During visit on 05/19/2025, LPA toured the first-floor dining room and kitchen, second floor dining room and kitchen, and memory care dining room and kitchen. LPA observed no cockroaches in any of the dining rooms and kitchens. LPA observed cockroach traps in the first-floor kitchen and memory care kitchen.

13 out of 13 interviewed staff stated to have observed cockroaches in the facility. 1 out of 11 residents stated to have observed cockroaches in the facility. 10 out of 11 residents stated to have not observed cockroaches in the facility.

Allegation: Staff do not treat residents with respect – Unsubstantiated

When the department received the complaint, it was alleged that staff do not treat residents with respect.

13 out of 13 interviewed staff stated to have not observed staff treating residents with disrespect.

9 out of 11 interviewed residents stated to have not observed staff treating residents with disrespect. 2 out of 11 interviewed residents stated to have experienced staff treating them with disrespect. The 2 residents who stated staff treated them with disrespect could not provide the names of the staff whom they allege treated them with disrespect.

Page 2 of 3.

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20250514114259

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/04/2026

NARRATIVE

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Allegation: Due to lack of staff, staff do not assist residents in their morning activities of daily living – Unsubstantiated

When the department received the complaint, it was alleged that staff do not assist residents with their activities of daily living.

13 out of 13 interviewed staff stated that the staff assist residents in their morning activities of daily living.

10 out of 11 interviewed residents stated that the staff assist residents in their morning activities of daily living. 1 out of 11 interviewed residents, resident R1, stated that on one occasion he/she had to get out of bed by himself/herself because staff did not arrive at his/her apartment; R1 stated he/she feared getting out of bed unassisted because he/she could fall and experiences dizziness.

On 05/27/2025, LPA Marrufo received R1’s Personal Service Plan via email from ADM. R1’s Personal Service Plan does not indicate whether R1 requires assistance to get out of bed on his/her own.

Based on information from interviews conducted with staff and residents, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with Assistant Executive Director Yasen Matar and a copy of this report was provided.

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END REPORT

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

LIC9099 (FAS) - (06/04)

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