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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202971
Report Date: 10/30/2025
Date Signed: 10/30/2025 09:38:19 PM

Document Has Been Signed on 10/30/2025 09:38 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:MARBELLA SAN JOSEFACILITY NUMBER:
435202971
ADMINISTRATOR/
DIRECTOR:		DONNER, ZEINABFACILITY TYPE:
740
ADDRESS:1009 BLOSSOM RIVER WAYTELEPHONE:
(408) 445-7770
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 153CENSUS: 96DATE:
10/30/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Zeinab Donner TIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted announced pre-licensing visit for Change of Ownership. LPA met with Executive Director/Administrator Zeinab Donner.

The visit is for a pre-licensing change of ownership of Brookdale San Jose with license #435202447 to Marbella San Jose #435202971. The facility will not change any structural or layout of the building. The facility will serve adults 60 and over and under the same program plan, including dementia program. Applicant will retain 143 non-ambulatory, 10 may be bedridden, memory care unit is for 31 with delayed egress and assisted living for 122 and a hospice waiver for 20.

The facility is composed of 3 parts, the assisted living and memory care section of the community will transition to the new ownership and applying for the license. Assisted Living has 61 rooms and Memory Care has 28 rooms. The independent living section of the community is not included in the licensing application.

LPA toured the facility inside and outside, assisted living area, memory care unit, dining area, salon, library, activity area, 3 kitchen including the main kitchen that prepares the meals for the entire community (assisted living, memory care and independent living).

LPA observed that residents were busy with different activities located at different areas of the assisted living and memory care. LPA observed memory care resident rooms are maintained and sanitary. The bathrooms have grab bars, and non-slip flooring. The hot water temperature is checked each week by the maintenance supervisor. “Oxygen in Use/No smoking” signs were observed posted outside the residents’ room where oxygen was administered.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MARBELLA SAN JOSE
FACILITY NUMBER: 435202971
VISIT DATE: 10/30/2025
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LP observed various on-going activities to celebrate 10/31/2025. Staff and residents were participating all throughout the facility. Activity calendar was observed posted at various locations throughout the facility. All common areas were free from obstructions, and hallways were well-lit.

LPA inspected activity areas, library, media room, Theater room, exercise room, and other commons areas and observed residents actively engaged in recreational programs and activities.

LPA observed the memory care rooms to be organized and sanitary, the kitchen is equipped with food warmers and has snack available for residents at all times.

LPA inspected laundry rooms on each floor and observed working washer and dryer units. Sharp objects, detergents, and chemicals were observed to be locked and inaccessible to persons in care. LPA observed locked centrally stored medication carts in the Assisted Living and Memory Care units.

LPA inspected the main kitchen and observed the kitchen to be organized and sanitary. The freezer and refrigerators are maintained at 0 degree F, the refrigerator is maintained at 32 degree F and checked temperature and log 5 times a day. LPA observed two (2) days of perishable food and nonperishable food for seven (7) days and is able to sustain 160 staff and 294 residents overall (assisted living, memory care and independent living) in case of an emergency.

LPA toured the exterior part observed walkways are free from obstructions and tripping hazards. Delayed egress was observed in the memory care unit and a keypad to enter is required. No bodies of water was observed. LPA inspected observed fire extinguishers to be strategically placed in each floor and area of the Assisted Living and Memory Care that was recently inspected 10/13/2025. ED stated SSS Fire Protection Inc maintains their Automatic sprinkler systems quarterly and was checked last by SSS on 10/13/2025. Fire Detection Unlimited (FDU) and maintains the smoke alarm and carbon monoxide semi-annually and last inspection made was on 08/27/2025.

COMP III was presented during this visit. LPA did not observed any areas to be corrected and the facility is ready to be licensed. An exit interview was conducted Zeinab Donner, Executive Director/Administrator and a copy of this report was provided.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC809 (FAS) - (06/04)
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