435202447-4-21-2022-26-AS-CCHG-CDPKL2-20220421075911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 04/20/2022
Date Signed: 04/21/2022 07:59:56 AM

Document Has Been Signed on 04/21/2022 07:59 AM - 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 JOSE		FACILITY NUMBER:	435202447
ADMINISTRATOR:	MARIE HARRIS		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	153	CENSUS: 80	DATE:	04/20/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Marie Harris		TIME COMPLETED:	04:00 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) Steve Chang, Licensing Program Manager (LPM) Sarah Yip, Regional manager (RM) Vivien Helbling, and Program Clinical Consultant (PCC) Lori Kopplinger conducted Technical Assistant - PCC 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 dining room at the first floor. It was observed that the facility has 4 chairs at one table, and more than one table connected together with 6-8 chairs. Table cloths were observed on each table. Isolation rooms were observed in facility. Signage were observed on the doors of isolation rooms. PPE stations were observed outside the isolation rooms. Nurse consultant discussed with ADM on the infection control measures. Based on today's inspection, below are the recommendations:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: 04/20/2022

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
26
27
28
29
30
31
32

1. Facility to remove the table cloths on all tables in the dining room.
2. Facility to remove extra chairs to minimize the number of residents at each dining table.
3. Facility to keep social distancing in the dining room.
4. Facility to sanitize the salt and pepper shakers on each dining table after each use
5. Facility to have the trash cans with foot pedal in the isolation rooms.
6. Facility to conduct staff training at least quarterly or as frequently as needed on
donning and doffing of PPE ,COVID -19 updates by CDC, and/or local public
health and to review DSS-CCLD Providers Information Notice(PIN).
7. Facility to update the mitigation plan and submit the revised mitigation plan to CCL.
8. Facility to make sure that staff are fit tested annually.
9. Facility will discuss with LHD regarding the closure of dining room.

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 Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2