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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 01/27/2023
Date Signed: 01/27/2023 10:06:12 AM


Document Has Been Signed on 01/27/2023 10:06 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
CENTRAL COAST CR/RES, 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:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Executive Director, Ryan GolzeTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Simi Rai and LPA Manuel Monter conducted an unannounced annual inspection focusing on infection control. LPAs met with Executive Director, Ryan Golze, ClareBridge Program Manger, Sabrina Setz, and Maintenance Director, Arnulfo Cantu.

LPAs toured the facility to include the public restrooms, assisted living dining rooms, assisted living kitchens, living room, memory care dining room, memory care kitchen, memory care activity room, 2 resident rooms. Dining rooms and kitchen areas were observed within sanitary condition.

All fire exit routes are free and clear of obstruction. Toxins and sharp objects were secured. Medication stored in a locked room and medication cart was locked.

Facility observed to have a designated central entry point to include a sign-in sheet and temperature check. Facility clean and disinfect twice daily and as often as needed. Bathrooms supplied with hygiene products and hand washing sign. Trash can with lid observed.

LPAs observed a sufficient amount of Personal Protective Equipment (PPE). All staff are N95 fit tested. The following posters observed to include wash your hands, symptoms of COVID-19, and importance of wearing a mask.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Ryan Golze, and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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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