435202447-3-14-2025-26-AS-KHOS-DFBN7P-20250401101303

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 03/14/2025
Date Signed: 03/14/2025 03:54:42 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
03/03/2025 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20250303112256

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: 89	DATE:	03/14/2025
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Zeinab Donner - Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not ensure residents personal information was kept confidential

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver the findings of the complaint investigation that was conducted on 3/12/2025 and met with Executive Director (ED) Zeinab Donner.

On 3/12/2025, LPA requested ED to see the Financial Director (FD) office. LPA was accompanied by ED and observed that the office is located at a high traffic area of the facility near activity central area. LPA & ED observed that the door was unlocked and no staff was present in the office. LPA & ED observed stack of documents inside the office such as but not limited to checks with banking information, a box of file folders with resident's names and information, personnel reports, and other documents that may contain confidential & sensitive information and accessible to unauthorized individuals.

page 1 of 2 see LIC 9099C

Substantiated

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: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

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 3

Control Number 26-AS-20250303112256

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: 03/14/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/14/2025 Section Cited CCR 87468.2(a)(2)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1-Personal Rights of Residents in All Facilities...shall have all of the following personal rights: (2) To have their records and personal information remain confidential	1 2 3 4 5 6 7	ED stated that staff started to file and organize the office of the FD and a deadline was given to staff by end of next week (3/21/25). ED stated FD office staff started to lock the door including breaktime since 3/12/2025 and will be locked at all times.
	8 9 10 11 12 13 14	and to approve their release.. This requirement is not met as evidenced by: Based on interview & observation, FDs office door was unlocked with no staff present in the office. LPA & ED observed checks with banking information, set of keys	8 9 10 11 12 13 14	cont -A box of resident's folders, personnel files & other documents that contain sensitive informaton & were accessible to unauthorized individuals. S1 stated, the door is unlock when staff are not in the office for breaks. ED stated FD office should be locked at all times.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20250303112256

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: 03/14/2025

NARRATIVE

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Based on interviews:

ED stated, based on what was seen and observed FD Office should be secured at all times due to the sensitive information that are processed and the influx of confidential information received by the FD office.

S1 stated the door of the FD Office is not locked when staff needs to use the restroom or will be out of the office for a short period. The FD Office is locked if staff are out for extended period of time.

S2 stated the door is not lock so residents can freely go in and speak with staff in the FD office, but is not aware if the office is locked when there is no staff inside.

S3 stated he/she does not go in the FD Office at all.

Based on observation and interview the preponderance of evidence have been met, therefore, the allegation that staff did not ensure residents personal information was kept confidential is SUBSTANTIATED.

Citation is issued during today's visit based on California Code of Regulation (CCR) Title 22, Division 6, Chapter 8, Article 8, 87468.2 (a)(2). See LIC 9099D.

An exit interview was conducted with Executive Director (ED) Zeinab Donner. A copy of the report and appeals rights were provided.

Page 2 of 2
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: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3