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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 08/21/2025
Date Signed: 08/21/2025 04:44:29 PM

Substantiated


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
08/13/2025 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20250813105217
FACILITY NAME:BROOKDALE SAN JOSEFACILITY NUMBER:
435202447
ADMINISTRATOR:DONNER, ZEINABFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:153CENSUS: 93DATE:
08/21/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Zeinab DonnerTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not answer residents calls for assistance timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced initial complaint investigation visit and met with Administrator (ADM) Zeinab Donner.

During visit, LPA Marrufo obtained copies of facility records and interviewed residents and ADM.

An Incident Report submitted by the facility to the department on 08/06/2025 states that on 08/03/2025, resident R1 fell from his/her bed onto the floor, pushed his/her pendant, and called 911. The Incident Report states paramedics arrived and assisted R1 back into the bed. R1 refused to be transported to the hospital for evaluation.

See LIC9099-C page for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 26-AS-20250813105217
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: 08/21/2025
NARRATIVE
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LPA Marrufo obtained The Activity Report for R1's Apartment. The Activity Report for R1's Apartment indicates that on 08/03/2025 at 10:21 PM, R1's pendant has an "Assistance Required" activity. The response time is indicated to be 40 minutes and 35 seconds. The "Performed by" column is blank.

LPA Marrufo obtained copies of Corrective Action reports for staff S1 and S2. Both Corrective Action reports state, "...on 8/3/25 you failed to respond to two resident's pendant in a timely manner. This directly impacts our residents quality of care and safety that Brookdale is expected to provide."

During interview on 08/21/2025, resident R1 stated that he/she rolled out of his/her bed and could not pick himself/herself up from the floor. R1 stated to have pressed his/her emergency pendant about 20 minutes after falling to the ground. R1 stated to have been able to reach for the phone in his/her bedroom and called 911 about 30 minutes after pressing his/her emergency pendant. R1 stated the facility staff arrived in R1's bedroom after the paramedics had already arrived.

During visit on 08/21/2025, ADM stated that S1 and S2 reported to ADM that they had not received R1's emergency signal on their pagers. ADM stated to have checked their pagers and saw that R1's emergency signal was found in their pager histories.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information.

This report was reviewed with ADM Zeinab Donner and a copy of this report and appeal rights were provided.

Page 2 of 2.



END REPORT
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20250813105217
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff
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Licensee agrees to submit a Plan of Correction by POC date stating how the licensee conduct will in-service training to ensure that staff are sufficient in numbers and competent to provide the services necessary to meet resident needs, including responding to resident emergency signals in
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shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Licensee did not ensure that staff were competent to provide the services necessary to meet the needs of resident R1, who had fallen onto the floor and triggered his/her emergency pendant, which poses an immediate safety risk to residents in care.
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a timeframe that meets the residents' needs. Once training is complete, the licensee shall submit training records of staff, including names of staff trained, dates of training, and names and qualifications of trainers.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3