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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 12/03/2018
Date Signed: 12/22/2020 04:31:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BROOKDALE SAN JOSEFACILITY NUMBER:
435202447
ADMINISTRATOR:MICHELE MERRITTFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:153CENSUS: 92DATE:
12/03/2018
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Sean Fratellone and Christine BanglayTIME COMPLETED:
01:45 PM
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**This is an amended report to redact confidential names only. No other statements were amended.**

Licensing Program Analyst (LPA) Gladys Kuizon conducted an unannounced Case Management visit today and met with acting administrator Sean Fratellone and Health and Wellness Director Christine Banglay.

The purpose of LPA's visit was to verify and confirm that the facility received the Immediate Exclusion Letter for employee, S1, and that S1 is no longer present at the facility.

Based on interview with Sean and Christine and LPA's observation during today's visit, LPA has verified that S1 is not present, employed or residing at the facility. Licensee has been advised to disassociate S1 from their roster. An updated LIC 500 was received by LPA via email today.

Verification of removal is complete. Exit interview conducted with Sean and Christine.

SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2018
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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