435202447-7-14-2023-26-AS-RMAO-CU7246-20230728170325

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 07/13/2023
Date Signed: 07/14/2023 07:53:04 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/05/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20230705155702

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: 83	DATE:	07/13/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Bruce Herman		TIME COMPLETED:	04:38 PM

ALLEGATION(S):

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Facility has a cockroach infestation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Complaint Investigation visit and met with Assisted Living Director Bruce Herman (BH) to investigate a complaint that the facility has cockroach infestation.

LPA Chang toured the facility with BH in the following areas of the facility, the main dining room, main kitchen, memory care unit dining room, and 2 assisted living unit dining rooms wherein no presence of infestation such as cockroach, ant and other insects found.

LPA interviewed BH. BH stated does not have knowledge of infestation of cockroach in both assisted living unit and memory care unit. BH stated that he has no knowledge of independent living unit hence it is not within his jurisdiction as it is not licensed by CCLD.

Continue on LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

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-20230705155702

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/13/2023

NARRATIVE

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Based on interview with BH, I1 does not reside in Assisted Living or Memory Care Unit. I1 resides in the independent living portion of the facility not licensed by CCLD. I1 is independent and was not present at the facility during visit.

LPA interviewed 3 assisted living unit residents (R2 - R4) and memory unit residents (R5 - R7) in their bedrooms including 4 independent living unit residents (I8 - I11) and 1 private caregiver (PC1). Based on interviews with R2-R7, they all stated that there was no infestation in the facility including their respective bedrooms.

LPA interviewed the facility housekeeper (S1). S1 stated he/she did not find any cockroach in assisted living unit and memory care unit.

Based on the inspections, observations and interviews conducted, the facility does not have infestation of cockroaches or other bugs in both assisted and memory care units; however, the facility's independent living unit had cockroaches. The facility independent living unit is not licensed by CCLD, or CCLD has an authority. Therefore the investigation finding for today's visit is unfounded.

Exit interview was conducted with BH, The report was provided to BH for signature. a copy of the report was provided to BH.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC9099 (FAS) - (06/04)

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