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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 03/20/2025
Date Signed: 03/20/2025 04:23:07 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
04/21/2022 and conducted by Evaluator Christine Kabariti
COMPLAINT CONTROL NUMBER: 26-AS-20220421084439
FACILITY NAME:BROOKDALE SAN JOSEFACILITY NUMBER:
435202447
ADMINISTRATOR:MARIE HARRISFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:153CENSUS: DATE:
03/20/2025
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Zeinab DonnerTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Residents records medical assess(forms) are not updated annually.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the findings for the above allegations. LPA met with Administrator, Zeinab Donner.

On 04/21/2022, the Department received the complaint. On 04/28/2022, the initial complaint investigation was conducted. The following records were obtained for this investigation to include the staff schedule, staff roster, 6 resident’s physician’s report, personal service plan, and progress notes.

It was alleged that resident’s medical assessment forms are not being updated annually and that some residents do not have a medical assessment form on file.
Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine KabaritiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
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 6
Control Number 26-AS-20220421084439
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: 03/20/2025
NARRATIVE
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7 resident records were requested. Based on record review, 6 out of 7 resident’s records were obtained. The facility was unable to produce 1 out of 7 resident records to include the resident's medical assessment.

The review of records shows that 3 out of 7 residents did not have a medical assessment (physician’s report) on file.

4 out of 7 residents had a medical assessment on file that was updated.

The Department has investigated the above allegation. Based on record review the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulation, Title 22. See LIC9099-D.

This report was reviewed with Executive Director, Zeinab Donner and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine KabaritiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20220421084439
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: 03/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2025
Section Cited
CCR
87506(b)(10)
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(b) Each resident’s record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions. This requirement is not met as evidenced by:
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Licensee states all the residents has an assessment and medical assessment on file now. Licensee will submit this statement in writing to LPA Kabariti via email by POC due date.
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Based on record review and observation, the licensee did not ensure 3 residents had a medical assessment on file which poses/posed a potential health, safety, and personal rights risk to persons in care.
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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine KabaritiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
04/21/2022 and conducted by Evaluator Christine Kabariti
COMPLAINT CONTROL NUMBER: 26-AS-20220421084439

FACILITY NAME:BROOKDALE SAN JOSEFACILITY NUMBER:
435202447
ADMINISTRATOR:MARIE HARRISFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:153CENSUS: DATE:
03/20/2025
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Zeinab DonnerTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Residents do not have updated care plans
Facility does not have sufficient staff to meet the needs of the residents
Resident left in soiled diaper
Resident not fed a meal
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director, Zeinab Donner.

On 04/21/2022, the Department received the complaint. On 04/28/2022, the initial complaint investigation was conducted. The following records were obtained for this investigation to include the staff schedule, staff roster, 6 resident’s physician’s report, personal service plan, and progress notes.

It was alleged that resident’s level of care has increased, however, their care plans are not being updated to reflect their actual care needs. It was alleged that resident (R1) required a two-person assist. Page 1 of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine KabaritiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20220421084439
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: 03/20/2025
NARRATIVE
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6 resident’s care plans were obtained and reviewed. Based on record review, 6 out of 6 resident’s care plans were updated in year 2022, prior to opening the complaint investigation. Based on record review of R1’s care plan, R1 required assistance with activities of daily living to include dressing, grooming, showers, and bathroom assistance. It shows that R1 required assistance with transferring however, R1 did not require a two-person assist.

On 04/28/2022, a staff member (S1) was interviewed. Based on staff interview, it was stated that the facility completes a pre-admission appraisal during admission, the second service plan is completed 13-14 days after the move, and again at 6 months unless there is a change in condition.

Facility does not have sufficient staff to meet the needs of the residents
It was alleged that the facility does not have sufficient staff to meet the needs of the resident based on an issue that arose on 04/16/2022. It was alleged that on 04/16/2022, there was just 1 medtech and 1 agency staff working in assisted living when there are normally 3 caregivers and 1 MedTech during the AM and PM shift. It was alleged that there were no Brookdale caregivers who showed up that day.

Based on review of the facility’s staffing schedule, on 04/16/2022 there was 3 staff scheduled for the AM (6am – 2pm) shift and PM (2pm – 10pm) shift.

On 04/28/2022, the Executive Director was interviewed. Based on interview, the facility utilized a software program to determine the core staff needed to meet the residents needs. It was stated that the program is updated every 2 weeks to determine what services are needed and hours of staffing needed to complete the service tasks for medtechs, caregivers, housekeeping and dining staff.

Based on interview with the ED, it was stated that staffing has been tight during their recent COVID-19 outbreak on 04/13/2022, however, the residents needs are being met. ED states that the facility also utilized outside staffing agencies to support staffing needs, however, are phasing out of the staffing agency and hiring more staff. Page 2 of 3.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine KabaritiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20220421084439
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: 03/20/2025
NARRATIVE
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Resident left is soiled diaper
It was alleged that due to the staffing shortage on 04/16/2022, a resident (R1) waited on the toilet for more than 30 minutes, with his/her legs and scooter covered in fecal matter.

Based on record review, R1 required assistance with activities of daily living to include bathroom assistance and transferring. There was no indication on file to prove that R1 waited on the toilet for more than 30 minutes and covered in fecal matter.
On 03/05/2025, it was found that R1 no longer resides from the facility.

Based on staff interview, 2 out of 2 staff could not recall a time where R1 was left soiled and covered in fecal matter.

Resident not fed a meal
It was alleged that a resident (R2) had been left in bed all day until about 1:00pm with no breakfast or lunch.

The facility was unable to produce documentation for R2.

Based on staff interview, 2 out of 2 staff could not recall a time where R1 was not provided a meal. It was stated that residents are provided 3 meals a day. Staff stated that if a resident is unable to have a meal in the dining room, they would provide resident meals to their bedroom.

The Department has investigated the above allegations. Based on interview, record review, and observation the above allegations are unsubstantiated. An unsubstantiated finding means that although the allegation is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Zeinab Donner and a copy of the report was provided. Page 3 of 3.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine KabaritiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6