435202447-9-27-2024-26-AS-RMAO-DAHREG-20241029125733

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 09/27/2024
Date Signed: 09/27/2024 01:47:14 PM

Unfounded

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
09/20/2024 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20240920124622

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: 85	DATE:	09/27/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Zeinab Donner - Executive Director/Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility did not adhere to smoking policy resulting to infrigement of residents' personal rights.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit for the complaint received by the Department. LPA met with executive director/administrator (ED/ADM) Zeinab Donner and stated the purpose of the visit.

On 9/20/2024, the department received a complaint that the facility did not adhere to smoking policy resulting in to infringemnet of resident's personal rights.

On 9/27/2024, LPA Partoza, conducted a complaint investigation. LPA requested for documents from ED/ADM, conducted inspection and interviews with residents and ED/ADM.

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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-20240920124622

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: 09/27/2024

NARRATIVE

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On 9/27/2024 at 10:30 a.m. LPA with ADM toured the independent living area and the assisted living area of the community. The independent living is located on third floor east side of the community and the assisted living is located on the east side 2nd and 1st floor of the community.

At 10:30 a.m. LPA interviewed ED/ADM. ED/ADM stated R1 has complained multiple times that R2 smokes at different times of the day and have called the front desk multiple times. ED/ADM have staff check on R2 whenever R1 calls to report that R2 is smoking. ED/ADM stated that front desk staff checked R2s apartment 3 times at one time, when R1 reported R2 was smoking during the evening. ED/ADM stated the staff reported via email of what had happened and did not see R2 smoking and observed R2 sleeping at the time R1 reported R2 was smoking. ED/ADM stated that R2 smokes however R2 goes to the parking lot to smoke. ED/ADM stated that he/she did have a conversation with R2 regarding smoking policy inside and outside the apartment when R2 was first reported by R1 that R2 was smoking on the balcony of his/her apartment. ED/ADM stated since the conversation R2 walks towards the parking lot to smoke. ED/ADM stated that the next plan will be to post a no smoking sign at the staff break room which is two doors from R2s apartment and will have staff go to R1s apartment to check where the cigarette smoke is coming from.

At 11:40 a.m. LPA interviewed R1 and R1 stated that the person below smokes anytime of the day and evening. R1 stated he/she saw the person sitting at the corner of the balcony smoking and complained to management. R1 stated that since then it's been constant and have called the front desk multiple times. R1 stated the smoking happens early evening after dinner, last night (9/26) at 10:15 p.m. and at 2:45 a.m. the night before (9/25). LPA did not observe cigarette smell at the time of the visit from R1s apartment. LPA informed R1 that Community Care Licensing Division (CCLD) does not have jurisdiction over the independent living area of the community.

At 12:00 p.m. LPA with ED/ADM inspected resident 2 (R2) apartment who lives in the assisted living area of the community directly below R1s apartment. LPA observed cigarette smell from R2s apartment when R2 opened the door. LPA interviewed R2 who stated that he/she does not smoke in the apartment when R2 had a conversation with ED/ADM regarding the community policy on cigarette smoking in the apartment inside and outside after the incident of 8/29/24. LPA with ED/ADM inspected restroom, bedroom, kitchen, living room and patio of R2s apartment and did not observe signs of smoke or cigarette inside and outside (balcony) of the apartment. R2 stated to LPA since the incident R1 never stopped complaining even though R2 no longer smokes inside or outside the apartment.

~~~~ page 2 of 3 - see LIC 9099C

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20240920124622

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: 09/27/2024

NARRATIVE

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Based on document review the facility have implemented smoking policy to R2 and responded to R1s complaint by sending a staff to R2s apartment to check if R2 is or was smoking at the time of the call received from R1. ED/ADM is working with both R1 and R2 to resolve the issue.

This agency has investigated the complaint alleging facility did not adhere to smoking policy resulting to infrigement of reidents' personal rights.We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies were cited during today's visit based on California Code of Regulation (CCR) Title 22. An exit interview conducted and a copy of the report was provided.

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end of report.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

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