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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294156
Report Date: 10/12/2020
Date Signed: 10/13/2020 09:37:22 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 SCOTTS VALLEYFACILITY NUMBER:
445294156
ADMINISTRATOR:HARRISON, PAULFACILITY TYPE:
740
ADDRESS:100 LOCKEWOOD LNTELEPHONE:
(831) 438-7533
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:220CENSUS: 130DATE:
10/12/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Marie HarrisTIME COMPLETED:
03:30 PM
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Licensing Program Analyst Ryker Heberle (RH) conducted an unannounced case management tele-visit with Executive Director Marie Harris (ED) via Facetime. This case management visit was to conduct a health and safety check and ensure the facility is adhering to health protocols.

LPA toured the facility's common areas, dining room, public bathrooms, medicine room, kitchen, hallways, offices, and a bedroom. LPA observed that the facility is well lit, clean, and in good repair. Temperature was observed as being kept at 75 F. Water and lights were observed to be working in resident apartments and throughout facility.

LPA observed 2 days of perishables and 7 days of nonperishable food. Tables and chairs in the dining area were observed to be adequately spread at least 6 feet apart from one another. ED informed LPA that communal dining is carried out in shifts.

Bedroom and bathrooms observed to be clean and sanitary. Hygiene items and toiletries observed to be available to residents.

Centrally stored medications were locked and inaccessible to the residents.

Facility observed to be following pandemic health protocols

No deficiencies were cited during today's visit

This report was reviewed with Administrator Marie Harris on 10/13 and a copy of this report was provided to Administrator Marie Harris for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2020
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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