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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 11/08/2022
Date Signed: 11/08/2022 12:59:44 PM


Document Has Been Signed on 11/08/2022 12:59 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:SHARON MONCKFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:153CENSUS: 77DATE:
11/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Audrey BuiTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management visit, and met with Associated Executive Director (AED) Audrey Bui.

LPA addressed the purpose of the visit to AED that the Department received an incident report on 11/02/2022 regarding a staff yelled at a resident.

LPA interviewed AED, a resident R1, and two family members of R1.

AED stated the facility already had started the investigation regarding this incident, and suspended the suspect staff.

AED stated the facility will provide the training of
1. Challenging behavior, intervention and redirection.
2. Behavior problem solving.
3. Resident personal rights.
to staff.

AED stated AED will send the signatures of staff for the training to LPA.

No citation was noted today. Exit interview was conducted with AED This report were provided to AED for record.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
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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