435202447-2-1-2024-26-AS-CDOS-D222QE-20240131163549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 01/31/2024
Date Signed: 02/01/2024 08:22:59 AM

Document Has Been Signed on 02/01/2024 08:22 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 JOSE		FACILITY NUMBER:	435202447
ADMINISTRATOR:	RYAN GOLZE		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	153	CENSUS: 71	DATE:	01/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Zeinab Donner		TIME COMPLETED:	04:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Executive Director (ED), Zeinab Donner. During visit, LPA and ED toured the Assisted Living section of the facility to include 8 resident apartments, dining rooms, kitchens, activity rooms, and hallways. Due to the active COVID-19 outbreak in memory care, LPA did not enter the memory care section. The facility's temperature was maintained between 72 - 75 degrees Fahrenheit. Fire extinguishers last serviced on 10/04/2023. Smoke and carbon monoxide detectors present throughout the facility. The fireplace in the main lobby area observed screened. All fire exit routes were free and clear of obstruction. The facility has an updated emergency disaster plan. LPA observed the facility conducts emergency drills quarterly and the last drill was completed in December 2023. Facility has emergency lighting installed throughout the hallways. Emergency non-perishable foods were observed. LPA observed multiple emergency food items were expired to include cases of orange juice, apple juice, water bottles, lemon pudding, and boxes of cookies / crackers. ED states their plan to go through their emergency food supply and replenish the items that are expired. 8 out of 8 resident apartments observed with adequate lighting, beds, linens, dressers, chairs, and night stands. Resident bathrooms supplied with non-slid floors and grab bars. LPA observed two PPE carts located outside 2 resident's apartments to be complete. LPA observed an open trash can near the PPE cart and advised to place a lidded trash bin next to the PPE carts. SEE LIC809-C.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/31/2024

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The facility has an infection control plan. Staff were provided training on infection control and prevention and food handling in year 2023.

The facility has 2 kitchens located in Assisted Living (AL). 2 out of 2 kitchens observed are kept clean with no observations of litter, rodents, vermin, and insects. No observations of soaps, chemical, and cleaning solutions commingling with the food supply. All meals are prepared in the Independent Living kitchen and transferred to Assisted Living and Memory Care using a cart.

LPA reviewed 6 staff files to include a job application, health screening, and TB result. 6 staff files reviewed are fingerprint cleared and associated to the facility. LPA did not observed 6 staff members 1st aid certification during visit.

Posters and signs observed to include the ombudsman, complaint poster, personal rights, activities calendar, and fire exit routes.

Due to insufficient time, LPA will continue the annual inspection on another day.

This report was reviewed with Executive Director (ED), Zeinab Donner 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: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC809 (FAS) - (06/04)

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