435202447-6-21-2023-26-AS-KHOS-CTDJYL-20230703072808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 06/21/2023
Date Signed: 06/21/2023 12:26:49 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
06/13/2023 and conducted by Evaluator Christine Dolores

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230613132925

FACILITY NAME:	BROOKDALE SAN JOSE		FACILITY NUMBER:	435202447
ADMINISTRATOR:	SHARON MONCK		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	153	CENSUS: 69	DATE:	06/21/2023
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Ryan Gozle		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility does not have an evacuation plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Executive Director (ED) Ryan Golze. Assistant Executive Director (AED) Audrey Bui, and Maintenance Director (MD), Arnulfo Cantu.

During visit, LPA toured the facility with the MD to include the common areas, independent living, assisted living, and memory care. Based on observation, the first – third floor of the independent living section did not contain an evacuation map. The facility was verbally advised.

The first – second floor of the assisting living section contained evacuation maps posted throughout the hallways and near the exit areas. LPA observed the facility’s emergency disaster plan posted in the lobby of assisted living dated in year 2021. At the end of the tour, the facility provided LPA an updated emergency disaster plan dated 01/01/2023. AED states the emergency disaster plan was updated in their system but was not posted in a visible area. SEE LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230613132925

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: 06/21/2023

NARRATIVE

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The first floor of the memory care section contained emergency exiting plans posted throughout the hallways and near the exit areas.

Based on observation, the emergency exiting plan in assisted living and memory care are printed on letter size paper approximately 8.5 x 11 inches. Based on interview, the residents have complained about the size of the emergency exit plan posters and requested them to be printed in a larger size. ED states to have already ordered emergency exit plans (evacuation maps) in a larger print. LPA obtained a receipt to show the facility has ordered larger evacuation maps for the facility.

Based on record review, facility staff per each shift are provided training in Evacuation, Disaster, and Fire drills with a vendor starting March 2023 – June 2023. The facility also has a 2023 Emergency Manual located at the front desk and is readily available for review upon request.

Based on interview, the residents were provided a presentation from a fire inspector about two months ago. The information provided to the residents included but not limited to evacuation plans, proper exiting, and taking precautions in case of an emergency. The residents were also given time to ask questions.

The following documents were obtained for this investigation to include the resident roster, emergency disaster plans, fire drill reports, building evacuation assembly sites, contracts, and the fire inspector’s contact information.

The Department has investigated the above allegation. Based on record review, interview, and observation the allegation is unsubstantiated. An unsubstantiated finding means although the allegation may have happened and/or is valid there is not a preponderance amount of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director (ED) Ryan Golze. Assistant Executive Director (AED) Audrey Bui, and Maintenance Director (MD), Arnulfo Cantu and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

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