435202447-5-2-2025-26-AS-KHOS-DGLSAU-20250512134256

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202447
Report Date: 05/02/2025
Date Signed: 05/02/2025 04:02:22 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
01/06/2022 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20220106154534

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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Staff entered residents room without permission and went through residents personal belongings

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 January 6, 2022, the Department received a complaint alleging Staff entered residents room without permission and went through residents personal belongings

Based on the phone interview conducted on 1/7/2022, by LPA Marrufo with R1s family member, R1 was residing on the 3rd floor of the independent living area of the community/facility.

On January 14, 2022, LPA David Marrufo conducted an initial investigation.

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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)

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Control Number 26-AS-20220106154534

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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LPA Marrufo interviewed Administrator (ADM)Marie Harris. During interview, Administrator Harris stated that the staff member walked into an independent living apartment. ADM stated it is on camera. ADM stated she spoke with staff S1 after the incident. ADM stated, S1 told her that he/she didn’t know why he/she went in and was just went snooping. ADM stated she asked S1 why did he/she open the cabinets, and he/she said I don’t know. ADM stated S1 didn’t displace anything or pick anything up.
ADM stated S1 was suspended pending investigation and then terminated. ADM stated S1 was suspended that same night.

On May 23, 2024 - LPA Partoza, conducted a continuation of the complaint investigation. Based on Interview with current executive director/administrator (ED/ADM) and Assisted Living Director (ALD), the area were the incident occurred on 1/3/2022, is an independent living area of the community/ facility and is not licensed by CCLD. The department does not have jurisdiction over the independent living section of the facility.

Based on record review, the facility conducted an internal investigation and have terminated the employment of the staff (S1) on January 14, 2022.

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, as the area were the incident occurred on January 3, 2022, is an independent living area of the community/facility and is not licensed by CCLD.

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)

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