435202447-1-6-2021-26-AS-GKUN-BWZP9F-20210106100703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202447
Report Date: 12/23/2020
Date Signed: 01/06/2021 10:07:19 AM

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 JOSE		FACILITY NUMBER:	435202447
ADMINISTRATOR:	ODETTE COLONDRES TORRES		FACILITY TYPE:	740
ADDRESS:	1009 BLOSSOM RIVER WAY		TELEPHONE:	(408) 445-7770
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	153	CENSUS: 89	DATE:	12/23/2020
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Marie Harris		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Gladys Kuizon conducted a Technical Assistance tele-visit today with CA Department of Public Health (CDPH) Health Facilities Evaluator Nurse (HFEN) Barbie Henson, RN. Present in the tele-visit were Executive Director (ED) Marie Harris, Health and Wellness Director (HWD) Geraldine Veras, District Director of Operations Jeff Toomer (DDO), District Director of Clinical Services Lori Fries RN, and District Compliance Specialist Jina Amstutz RN. At 9:32 AM, the facility was toured starting from the facility's main entrance. Per ED and HWD, all visitors, staff and residents are screened at this entrance. LPA observed COVID-19 related postings and signage by entrance. A screening station was observed with sign-in sheets and symptom checking by an assigned staff member. At 9:43 AM, the Assisted Living (AL) building was toured. COVID-19 postings were displayed in conspicuous places to alert individuals of isolation areas and Personal Protective Equipment (PPE) use requirement. The dining rooms were observed closed and not in use. Common bathrooms were equipped with hand soaps, paper towels, and covered trash bins. The facility has a designated staff break room. Social distancing sign was observed prior to entering the elevator. The facility has a designated Special Isolation Unit (SIU) were COVID-19 positive residents are cohorted. Per DDO, the SIU is equipped with air deionizers, HEPA filters, and air flow management system which is tested twice a week. The SIU was observed with plastic protective barriers and a designated donning and doffing area by the central entrance and exit. Continued, see LIC 809-C, page 2 of 2.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 JOSE	FACILITY NUMBER: 435202447
	VISIT DATE: 12/23/2020

NARRATIVE

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The following were recommended by HFEN today:

1. Hand-washing guide shall be posted in every hand-washing station.

2. Limit the number of seating or configure chairs to promote at least 6 feet of social distancing in common areas, including Associate Lounge/staff break room.

3. Ensure covered trash bins are used throughout the facility. A trash bin with a foot pedal is highly recommended to avoid users from touching the lid.

4. Ensure disinfection of common areas, including Associate Lounge/staff break room. Posters shall be displayed to remind staff to sanitize after every use.

5. Post PPE donning and doffing diagram guide on all donning and doffing stations including inside and outside of isolation rooms outside of SIU. Ensure donning and doffing stations are equipped with all necessary PPEs (e.g. N95 masks)

6. An enclosed drawer or cart is recommended to protect clean PPE from contamination in donning and doffing stations.

7. The use of an automatic hand sanitizer dispenser by donning and doffing stations is recommended to minimize users from touching hand sanitizer bottles and possibly cross contaminating clean PPE.

8. Paper hand towels shall be placed in spindles or dispensers to protect against contamination.

No deficiencies were cited. These recommendations and report were discussed with the Brookdale management team today and a copy was provided to ED Marie Harris for review and signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020

LIC809 (FAS) - (06/04)

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