435202447-11-17-2020-26-AS-GKUN-BVFPUS-20201117103758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 11/16/2020
Date Signed: 11/17/2020 10:38:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	ODETTE COLONDRES TORRES		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	153	CENSUS: 90	DATE:	11/16/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Antonette Edwards, Assisted Living Director Geraldine Veras, Health & Wellness Director		TIME COMPLETED:	05:22 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) Gladys Kuizon conducted a case management tele-visit today with CA Department of Public Health (CDPH) Health Facilities Evaluator Nurse (HFEN) Rebekah Bird-Wohlgemuth. Present during tele-visit were Assisted Living Director (ALD) Antonette Edwards, Health and Wellness Director (HWD) Geraldine Veras, District Director of Operations Jeffrey Toomer, and Licensing Program Manager (LPM) Romeo Manzano. At 3:11 PM, the facility was toured including Memory Care (MC) and Assisted Living (AL) bedrooms and bathrooms, common bathrooms, MC and AL dining rooms, staff breakroom, medications rooms, and central entrance. Screening procedures were reviewed for all individuals entering the facility. COVID-19 postings were observed on the entrance doors, hallways, hand-washing stations, and common areas. The toured ended at 5:22 PM. Staff were observed wearing personal protective equipment (PPE) including a face shield over a disposable surgical mask. Communal dining in MC is permitted for residents who are unable to dine in their rooms due to behaviors. Residents were observed seated at least 6 feet apart and using disposable plates and utensils. Dining rooms in AL remain closed and no staff or residents were observed present in the dining room. Continued, see LIC 809-C, page 2 of 2.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020

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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BROOKDALE SAN JOSE	FACILITY NUMBER: 435202447
	VISIT DATE: 11/16/2020

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The following improvements were advised today:

1. Posters outside elevators to remind users to maintain social distancing. Due to size of elevators, permit only one resident (and caregiver, if necessary) at a time.
2. Posters outside staff break room indicating a maximum permitted occupancy. Due to size of breakroom, only 4 staff members should be permitted at a time.

3. Ensure all trash bins have covers. Covered trash bins with foot pedals are recommended to minimize staff/residents from touching surfaces with their hands.

4. Mount paper towel rolls in dispensers/spindle to avoid contaminating unused towels in common areas (e.g. break rooms, bathrooms, kitchen).

5. Ensure updated list of COVID-19 symptoms are used for screening. Post symptoms questionnaires by entrance screening area.

Facility will be sending the following to Community Care Licensing Division:

1. Infection Control and Mitigation Plan

No deficiencies were cited today. A copy of this report was provided to ALD and HWD via email for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020

LIC809 (FAS) - (06/04)

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