435202447-12-18-2024-26-AS-KHOS-DENQKA-20250311121401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 12/18/2024
Date Signed: 12/18/2024 12:32:15 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
01/05/2024 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20240105145735

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: 98	DATE:	12/18/2024
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Zeinab Donner		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident's medications were observed scattered on the floor and in closet in resident's bed room.
Resident did not provide care and supervision to residents while on duty.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Executive Director Zeinab Donner. On 01/05/2024, the Department received a complaint with the above allegations. On 01/10/2024, LPA Marrufo conducted an initial complaint investigation visit. On 09/27/2024, LPA Maria “Mita” Partoza conducted an additional investigation visit.

R1’s Responsible Person provided LPA Marrufo with a digital photograph of a pill in the his/her hand. R1’s Responsible Person stated during interview on 01/10/2024 to have found the pill in R1’s bedroom on 11/06/2023 and gave the pill to a medication technician. The metadata of the digital photograph indicated the photograph was taken on 11/06/2023.

See LIC9099-C for more information. Page 1 of 3.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	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.

LIC9099 (FAS) - (06/04)

Page: 1 of 9

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
01/05/2024 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20240105145735

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: 98	DATE:	12/18/2024
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Zeinab Donner		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident's room was stinky.
Resident was left wearing underwear and the same shirt for 3 days without changing in the room.
Facility had shortage of staff.

INVESTIGATION FINDINGS:

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During visit on 01/10/2024, LPA Marrufo interviewed staff S1-S6.

S1 and S5 stated R1 would have lots of accidents in the bathroom and would often urinate on the bathroom floor. S1 stated staff would attempt to enter R1’s room to clean it, but R1 would become combative and not permit staff to enter R1’s room. S1 stated staff would attempt to convince R1 to leave R1’s room or wait until R1 was sleeping to clean R1’s room. S5 stated staff put R1 on two-hour room checks.

S2 stated staff would clean R1’s room whenever R1 urinated on the floor of R1’s room and would launder any of R1’s soiled clothing. S3 stated that scented plugins were installed in R1’s room and R1’s room did not have a foul smell. S4 and S6 stated to have not observed any foul smell in R1’s room.

See LIC9099-C for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	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.

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 26-AS-20240105145735

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: 12/18/2024

NARRATIVE

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During visit on 01/10/2024, LPA Marrufo toured 5 occupied resident living units. LPA Marrufo observed a slight urine odor in one of the 5 observed living units. In another of the five observed living units, LPA Marrufo observed the closet to have a wet blanket that smelled of urine. A staff told LPA Marrufo that the staff had not yet laundered the blanket. R1 had already moved out of the facility before LPA Marrufo’s visit, so LPA Marrufo was not able to observe R1 at the facility.

During visit on 09/27/2024, LPA Partoza observed two occupied resident living units and did not observe any foul odor.

LPA Marrufo obtained a copy of R1’s Care Profile, dated 10/12/2023. R1’s Care Profile states R1 demonstrates reluctance to accept dressing or grooming assistance, reluctance to accept bathroom assistance, and reluctance to go to and from the dinning room or community activities.

S1 and S2 stated R1 would refuse help getting dressed. S1 and S2 stated R1 would hang R1’s used clothes and wear them again the next day. S1 and S2 stated staff would lay out clean clothes in front of R1 and attempt to encourage R1 to wear clean clothes, but R1 refused to change clothes. S2 stated that staff notified R1’s Responsible Person multiple times about R1’s refusal to change clothes. S5 stated that R1 would deny that his/her clothes were dirty and would refuse S5’s encouragement to change clothes.

S3 and S4 stated R1 would change clothes by himself/herself. S6 stated to have observed R1 to be dressed well.

On 09/27/2024, LP Martoza interviewed 3 staff, who all stated to have never observed a resident being left in the same clothes for 3 days.

LPA Marrufo obtained a copy of the Rent Roll document, which states on that 11/06/2023 there were 29 residents residing in the Memory Care unit.

Page 2 of 3.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	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

LIC9099 (FAS) - (06/04)

Page: 4 of 9

Control Number 26-AS-20240105145735

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: 12/18/2024

NARRATIVE

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The Staff Schedule from 11/06/2023 states that there were 3 staff working from 2:00 PM to 10:00 PM and 1 staff working from 2:00 PM to 8:00 PM. The rest of the days of the month in the Staff Schedule for November indicate that there were 4 staff on duty per shift.

S1-S6 stated that there was a sufficient amount of staff in September through October of 2023. S1-S6 stated that there has never been a time when there are not enough staff to provide care and supervision of the residents.

Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22 at this time.

This report was reviewed with Executive Director Zeinab Donner and a copy of this report was provided.

Page 3 of 3.

END REPORT

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	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

LIC9099 (FAS) - (06/04)

Page: 3 of 9

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
01/05/2024 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20240105145735

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: 98	DATE:	12/18/2024
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Zeinab Donner		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility increased the monthly rent at 10% within 4 months.

INVESTIGATION FINDINGS:

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R1’s Admission Record states R1 was admitted to the facility on 08/31/2023.

R1’s Admission Agreement states, “F. RATE CHANGES. We will provide (60) days written notice of any change in the rates for Basic Services, Personal Services, Therapeutic Services or any other fees listed in this agreement.” R1’s Responsible Person signed R1’s Admission Agreement as R1’s Legal Representative on 08/23/2023.

LPA Marrufo obtained a copy of a letter from the facility and written to R1 on 10/20/2023. The letter states that R1’s pricing rates for Basic Services, Select Services, and Therapeutic Services will be increasing effective on 01/01/2024. There are 73 days between 10/10/2023 and 01/01/2024.

See LIC9099-C for more information. Page 1 of 2.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	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.

LIC9099 (FAS) - (06/04)

Page: 5 of 9

Control Number 26-AS-20240105145735

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: 12/18/2024

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 26 27 28 29 30 31 32	This agency has investigated the complaint allegations listed. Based on review of records, the CCLD has found that the complaint allegations are unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This report was reviewed with Executive Director Zeinab Donner and a copy of this report was provided. Page 2 of 2. END REPORT

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	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

LIC9099 (FAS) - (06/04)

Page: 6 of 9

Control Number 26-AS-20240105145735

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: 12/18/2024

NARRATIVE

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During interview on 01/10/2024, staff S4, who is a nurse at the facility, stated that a staff reported to S4 that a pill had been found in R1’s room. S4 stated to have destroyed the pill that was reported to have been found in R1’s room. S4 stated to have had a meeting with staff and told the staff not to leave pills on R1’s floor anymore. S4 told the staff that they should ensure that R1 is swallowing the medications.

During interview on 01/10/2024, S5, who at the time of the incident was the supervisor of the Memory Care unit, stated that R1’s Responsible Person informed S5 that R1’s Responsible Person observed a pill on the floor of R1’s bedroom. S5 stated that the pill on the floor was reported to the nurse on duty at that time.

LPA Marrufo obtained a copy of the Brookdale Associate Handbook. Page 42 states, “During working time, use of personal cell phones, pagers, or other electronic communications devices should be limited to emergency circumstances; this includes using the telephone or electronic communications device for text messaging…Abuse of these guidelines will result in corrective action, up to and including termination of employment.

LPA Marrufo obtained a copy of a Memo for All Staff, dated 11/08/2023. The Memo states that staff must check in on R1 in the AM and PM once every two hours with no exceptions. The Memo was signed by multiple staff, including S7.

LPA Marrufo obtained a copy of S7’s Corrective Action Plan dated 12/09/2023. The Corrective Action Plan states, “As a Caregiver, you [S7] are expected to follow posted care plans. However, on 11/12/23, you failed to meet the expectations of your position by Failed to assist a resident after a family member asked. Witnessed on your phone for 1.5 hours in a corner. This not only affects our residents; it affects your ability to work together with your peers.”

LPA Marrufo obtained a copy of a Notice to Employee as to Change in Relationship document. The document is addressed to S7 and was signed by a supervisor on 12/08/2023. The document states S7 was discharged on 12/08/2023.

Page 2 of 3.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	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

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 26-AS-20240105145735

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: 12/18/2024

NARRATIVE

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On 01/10/2024, R1’s Responsible Person stated during interview to have visited the Memory Care unit of the facility and observed a staff sitting alone in a dark corner of the facility while on his/her phone. R1’s Responsible Person stated to have observed the staff when he/she arrived and observed the staff to still be sitting while using his/her phone 1.5 hours later when R1's Responsible Person left the Memory Care unit.

LPA Marrufo obtained a copy of a text message from R1’s Responsible Person to S5 stating that S7 was sitting in a corner of the facility on his/her own phone the entire time that R1’s Responsible Person was visiting the facility.

During interview on 01/10/2024, S3 stated that S7 was R1’s assigned care giver.

S5, who was S7’s supervisor when R1’s Responsible Person observed S7 sitting for 1.5 hours while on the phone, stated that S7 was given a final corrective action. S5 stated to have interviewed S7. S5 stated to have asked S7 why he/she was sitting while on his/her phone for so long. S7 stated to have been taking his/her 30 minute lunch break and two 10 minute breaks consecutively. S5 stated S7 did not know why he/she was on the phone for so long. S5 stated to have asked S7 if S7 conducted his/her required two hour checks of R1, and S7 stated to not recall. S5 stated there are no logs for the two hour checks on R1.

Based on records review, interviews, and observations, there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegations are substantiated.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

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

Page 3 of 3.

END REPORT

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	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

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 26-AS-20240105145735

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: 12/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/19/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 (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 shall be employed to ensure provision of personal	1 2 3 4 5 6 7	Licensee agrees to submit a Plan of Correction by POC date explaining how the Licensee will ensure that staff are given in-service training to ensure that staff are competent to provide the services necessary to meet resident
	8 9 10 11 12 13 14	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 S7 was competent to provide the services necessary to meet resident needs instead of sitting in a corner of the facility while on the phone, which poses an immediate safety risk to residents in care.	8 9 10 11 12 13 14	needs, including not taking unplanned breaks and not using personal mobile phone or electronic devices for non-duty related reasons. Once training is completed, the Licensee shall submit copies of the training to CCL including names of staff trained, training dates, training topics, and names and qualifications of trainers.
Type A 12/19/2024 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place	1 2 3 4 5 6 7	Licensee agrees to submit a Plan of Correction by POC date stating how the Licensee will ensure staff receive in-service training to ensure that all centrally stored medications are kept safe and locked and inaccessible to residents.
	8 9 10 11 12 13 14	that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: Licensee did not ensure that a pill found in R1's Living unit was kept inaccessible to residents, which posed an immediate safety risk to residents in care.	8 9 10 11 12 13 14	Once training is completed, the Licensee shall submit copies of the training to CCL including names of staff trained, training dates, training topics, and names and qualifications of trainers.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

LIC9099 (FAS) - (06/04)

Page: 9 of 9