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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202447
Report Date:
12/18/2024
Date Signed:
12/18/2024 12:40:39 PM
Document Has Been Signed on
12/18/2024 12:40 PM
- 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/
DIRECTOR:
RYAN GOLZE
FACILITY TYPE:
740
ADDRESS:
1009 BLOSSOM RIVER WAY
TELEPHONE:
(408) 445-7770
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95123
CAPACITY:
153
TOTAL ENROLLED CHILDREN:
0
CENSUS:
98
DATE:
12/18/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:
Zeinab Donner
TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Executive Director Zeinab Donner.
The purpose of the visit was to amend a report that was delivered to the facility on 09/27/2024.
No deficiencies were cited at this time as per California Code of Regulations Title 22.
This report was reviewed with Executive Director Zeinab Donner and a copy of this report was provided.
Sarah Yip
TELEPHONE:
(408) 324-2131
David Marrufo
TELEPHONE:
(650) 380-0519
DATE:
12/18/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/18/2024
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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