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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 01/30/2025
Date Signed: 04/03/2025 01:36:26 PM

Document Has Been Signed on 04/03/2025 01:36 PM - 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: 101DATE:
01/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Zeinab DonnerTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Executive Director Zeinab Donner.

During visit, LPA toured the facility inside and out. LPA toured the kitchen areas and food storage areas. LPA observed a perishable food supply of at least 2 days and a non-perishable food supply of at least seven days. LPA observed the first aid kit and found it to be complete.

LPA observed emergency supply storage areas and activity room areas.

LPA toured 7 resident living units. Each living unit had available bedding and clothing storage areas as well as working lights. The water temperatures in the bathroom sinks of the 7 toured living units ranged from 105 F to 111 F. Each living unit had a bathroom with available soap and towels, non-slip mats in the shower, and working lights.

LPA reviewed the Centrally Stored Medication and Destruction Records (CSMDR) for seven residents and found them to be complete. LPA reviewed 7 resident records and found them to be complete. LPA reviewed 7 staff records and found them to be complete.

LPA reviewed facility Fire Alarm System Inspection records. The records indicate the facility fire alarm system passed all its inspection tests on 07/26/2024.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Executive Director Zeinab Donner and a copy of this report was provided.
Sarah YipTELEPHONE: (408) 324-2131
David MarrufoTELEPHONE: (650) 380-0519
DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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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