435202447-5-2-2025-26-AS-KHOS-DGLRVN-20250512132150

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 05/02/2025
Date Signed: 05/02/2025 04:00:37 PM

Unfounded

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
05/24/2021 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20210524084641

FACILITY NAME:	BROOKDALE SAN JOSE		FACILITY NUMBER:	435202447
ADMINISTRATOR:	MARIE HARRIS		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	153	CENSUS: 96	DATE:	05/02/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director Zeinab Donner		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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9

Staff not keeping the facility free of tripping hazards.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Executive Director Zeinab Donner.

On May 24, 2021, the Department received a complaint alleging Staff not keeping the facility free of tripping hazards.

On May 27, 2021, LPA Bui conducted an initial investigation and interviewed executive director and inspected resident apartments.

LPA Bui interviewed Executive Director (ED) Marie Harris. ED stated she has not seen any residents room with tripping hazards and has not heard of any staff or residents complaining of tripping hazards.
Page 1 Out of 2.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025

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 4

Control Number 26-AS-20210524084641

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: 05/02/2025

NARRATIVE

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On May 2, 2025, LPA Monter interviewed residents R1-R13. 10 Out of 13 (R1-R10) residents interviewed stated they have not observed any tripping hazards in the facility. 3 Out of 13 (R11-R13) residents interviewed declined to be interviewed.

LPA Monter interviewed staff S1-S10. All staff interviewed stated they have not observed any tripping hazards in the facility or in residents bedrooms.

LPA Monter interviewed Executive Director Zeinal Donner, who stated there are not any tripping hazards in the facility and if a tripping hazard is noted, it is addressed immediately.

On May 2, 2025, LPA Manuel Monter toured the facility assisted living section of the facility and randomly toured the following bedrooms: 161, 244, 231, 229, 230, 243, 152, 163, 156. While touring these bedrooms, LPA Monter observed the bedrooms as clean, safe and sanitary. LPA did not observe any tripping hazards.

LPA Monter toured all resident bedrooms in the memory care section of the facility: C1-C28. LPA Monter observed the bedrooms as clean, safe and sanitary. LPA did not observe any tripping hazards.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
05/24/2021 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20210524084641

FACILITY NAME:	BROOKDALE SAN JOSE		FACILITY NUMBER:	435202447
ADMINISTRATOR:	MARIE HARRIS		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	153	CENSUS: 96	DATE:	05/02/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director Zeinab Donner		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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9

Facility staffing is insufficient to meet resident's needs.

INVESTIGATION FINDINGS:

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13

On May 24, 2021, the Department received a complaint alleging Facility staffing is insufficient to meet resident's needs.

On May 27, 2022, LPA Bui conducted an initial investigation and interviewed executive director and inspected resident apartments.

LPA Bui interviewed Executive Director (ED) Marie Harris. ED stated they do not currently have a staff shortage. ED stated all the residents needs are being met with the current staff schedule.

Page 1 Out of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20210524084641

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: 05/02/2025

NARRATIVE

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12
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32

On May 2, 2025, LPA Monter interviewed residents R1-R13. 8 Out of 13 (R1-R8) residents interviewed stated they there is enough staff to meet their needs; such as, but not limited to showers, medications, laundry and housekeeping. 3 Out of 13 (R11-R13) residents interviewed declined to be interviewed. 2 Out of 13 residents (R9 & R10) interviewed stated there have been times when the facility has been short staffed and he/she needs to wait for more than 30 minutes for staff to respond to pendants.

LPA Monter interviewed staff S1-S10. 2 Out of of 10 Staff (S1-S2) stated the facility there have been times when the facility was short staffed, and wasn't enough staff to assist the residents. 8 out of 10 Staff (S3-S10) stated there is enough staff to meet the needs of residents in the facility.

LPA Monter interviewed Executive Director Zeinab Donner, who stated the facility has enough staff to meet the needs of residents in care.

On May 2, 2025, LPA Manuel Monter toured the facility assisted living section of the facility and randomly toured the following bedrooms: 161, 244, 231, 229, 230, 243, 152, 163, 156. While touring these bedrooms, LPA Monter observed the bedrooms as clean, safe and sanitary.

LPA Monter toured all resident bedrooms in the memory care section of the facility: C1-C28. LPA Monter observed the bedrooms as clean, safe and sanitary.

LPA tested the staff's response time to pendant activations. LPA tested the pendant in room 244 and staff responded in 2 minutes. LPA also tested the pendant in room 231, with a response time of 1 minute, 48 seconds.

During the tour of the facility, LPA did not observe any resident unkempt, un-showered or in an unsanitary state.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.
Page 2 Out of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4