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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 10/09/2020
Date Signed: 10/14/2020 09:14:27 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:MICHELE MERRITTFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:153CENSUS: 81DATE:
10/09/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Michele Merritt and Antonette EdwardsTIME COMPLETED:
10:36 AM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a Case Management tele-visit today. Due to COVID-19 restrictions, LPA met with Executive Director (ED) Michele Merritt and Assisted Living Director (ALD) Antonette Edwards through video conference.

The purpose of this visit was to re-visit and review facility's Non-Compliance Plan developed in December 2018.

LPA requested the following facility records: staffing schedule, staff training records, and facility menu.

LPA also discussed recently released COVID-19 related Provider Information Notice (PIN) 20-38-ASC regarding facility wide testing and visitations. Facility reported sufficient supply of Personal Protective Equipment (PPE) and access to COVID-19 testing to meet new requirements. Per ED, facility continues to follow guidance from Santa Clara County Health Department (SCCHD) which provides stricter protocols for re-opening communal dining at this time.

Facility's contact information was reviewed. Contact information was current and the facility confirmed receipt of PINs from Community Care Licensing Division and Everbridge Emergency Notification System.

No deficiencies were cited today. A copy of this report was provided to ED and ALD by email for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020
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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