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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 03/12/2025
Date Signed: 03/26/2025 08:25:13 AM

Document Has Been Signed on 03/26/2025 08:25 AM - 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 JOSEFACILITY NUMBER:
435202447
ADMINISTRATOR/
DIRECTOR:		RYAN GOLZEFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 153TOTAL ENROLLED CHILDREN: 0CENSUS: 89DATE:
03/12/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Zeinab Donner - Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted a case management visit regarding an incident that occurred on 02/19/2025. LPA stated the purpose of the meeting and met with Executive Director (ED) Zeinab Donner.

LPA discussed the incident report with ED and interviewed 2 staff who witnessed the incident. LPA requested copy of the disciplinary action. Personnel file of 2 staff, medication storage policy and procedure. Training logs for staff for medication administration and safeguarding of narcotic medication, duties and responsibility of caregivers and medication technicians and reporting procedures.

LPA Partoza determined that the incident requires further investigation.

No citation is issued during today's visit based on CCR Title 22. An exit interview conducted with Executive Director Zeinab Donner and a copy of the report was provided.
Romeo ManzanoTELEPHONE: (650) 388-2297
Maria PartozaTELEPHONE: (669) 308-3994
DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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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