445294156-7-8-2021-26-AS-SYIP-C5ATYK-20210726150850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 07/08/2021
Date Signed: 07/08/2021 04:24:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/17/2020 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20200917150121

FACILITY NAME:	BROOKDALE SCOTTS VALLEY		FACILITY NUMBER:	445294156
ADMINISTRATOR:	HARRISON, PAUL		FACILITY TYPE:	740
ADDRESS:	100 LOCKEWOOD LN		TELEPHONE:	(831) 438-7533
CITY:	SCOTTS VALLEY	STATE: CA	ZIP CODE:	95066
CAPACITY:	220	CENSUS: 132	DATE:	07/08/2021
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Nicole Bacon		TIME COMPLETED:	04:23 PM

ALLEGATION(S):

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Facility neglected to assess resident when resident sustained an injury
Staff failed to ensure resident was fed while in care
Staff is not answering the facility telephone

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and spoke with Nicole Bacon.

On 09/17/2020, the Department received a complaint investigation with the above allegations. The Department conducted an initial complaint investigation on 09/22/2020 and continued further interviews over telephone at later dates and reviewed facility records. In total, the department interviewed 11 residents and 7 staff.

See LIC9099-C for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 26-AS-20200917150121

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BROOKDALE SCOTTS VALLEY	FACILITY NUMBER: 445294156
	VISIT DATE: 07/08/2021

NARRATIVE

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Facility had to evacuate to Brookdale Redwood City and San Jose respectively on 8/20/2020. Per staff interview, the evacuation took place late in the afternoon and residents arrived at relocation sites around 2245 hours. Residents were provided snacks while in the bus and upon arrival, and residents were brought to the dining room after screening. Per S1, residents were served pasta with meat sauce, garlic bread, and desserts. Out of the 2 staff questioned if staff failed to feed residents on 08/20/2020, 1 of the 2 staff stated that the facility did feed the residents that night and 1 out of 2 staff stated to not have observed the residents arrive at the Brookdale Redwood City facility and therefore did not know.

11 out of 11 interviewed residents stated that they had not observed staff fail to ensure residents were fed while in care. 8 out of 11 residents stated that they were offered a meal upon evacuating to Brookdale Redwood City on the night of 08/20/2020; 2 out of 11 believed the first meal was breakfast as they arrived late in the night. 1 out of 11 residents stated he/she did not eat as it was late in the night. All 11 residents stated meals are normally always served on time.

11 out of 11 residents stated that they had not observed facility staff not answering the facility telephone. 2 out of the 2 staff who were asked if the staff failed to answer telephone calls coming from family members to the facility telephone on 08/20/2020 stated that they did not observe staff fail to do so.

LPA Marrufo conducted telephone calls to the facility at 10:30PM on 04/07/2021 and 10:00PM on 04/08/2021. LPA Marrufo was greeted by facility staff each time and was able to speak with staff.

See LIC9099-C for more information. Page 2 of 3.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20200917150121

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BROOKDALE SCOTTS VALLEY	FACILITY NUMBER: 445294156
	VISIT DATE: 07/08/2021

NARRATIVE

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The Department interviewed 7 staff. 5 out of 7 staff stated that resident R1 was assessed to have sustained a skin tear on R1’s lower left leg while boarding a facility bus during an evacuation on 08/20/2020. Facility staff S2 bandaged R1’s leg prior to evacuating the facility. 2 out of 7 staff stated upon arrival to Brookdale Redwood City, which was being used as an emergency relocation site, staff S4 cleaned and rebandaged R1’s skin tear. Per S4, R1’s cut was noted to have stopped bleeding and clotted when S4 cleaned and re-wrapped the cut. However, S4 did not document the care performed on R1 due to S4 not having R1’s chart available. S2 also stated that home health was requested and R1’s family was notified. R1 was interviewed and confirmed that S2 & S3 helped bandage R1’s cut while waiting on the bus and that staff changed R1’s bandage upon arrival at the relocation site. R1 also stated that 2 staff from Scotts Valley changed R1’s bandage before R1 was being picked up by family on 8/22/20.

The review of the progress notes noted that S2 responded to R1’s injury. S2 provided R1 with first aid by cleaning and bandaging the cut. R1 did not complain of pain or discomfort. Home health was arranged for R1 to receive care for the skin tear.

Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore the allegations are unsubstantiated

Page 3 of 3.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/17/2020 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20200917150121

FACILITY NAME:	BROOKDALE SCOTTS VALLEY		FACILITY NUMBER:	445294156
ADMINISTRATOR:	HARRISON, PAUL		FACILITY TYPE:	740
ADDRESS:	100 LOCKEWOOD LN		TELEPHONE:	(831) 438-7533
CITY:	SCOTTS VALLEY	STATE: CA	ZIP CODE:	95066
CAPACITY:	220	CENSUS: 132	DATE:	07/08/2021
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Nicole Bacon		TIME COMPLETED:	04:23 PM

ALLEGATION(S):

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Facility failed to seek timely medical attention for resident's injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and spoke with Nicole Bacon.

On 09/17/2020, the Department received a complaint investigation with the above allegation. The Department conducted an initial complaint investigation on 09/22/2020 and continued further interviews over telephone at later dates and reviewed facility records. In total, the department interviewed 11 residents and 7 staff.

See LIC9099-C for more information. Page 1 of 2.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20200917150121

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BROOKDALE SCOTTS VALLEY	FACILITY NUMBER: 445294156
	VISIT DATE: 07/08/2021

NARRATIVE

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7 out of the 7 staff interviewed regarding R1’s injury stated that R1’s skin tear injury did not appear deep despite substantial bleeding. R1 had not complained of pain after sustaining the skin tear. The facility did not document who assessed R1’s skin tear. R1 left the facility with a family member on 08/22/2020 and the family member did not seek medical attention for R1’s skin tear until 08/24/2020.

R1 was interviewed and confirmed that S2 & S3 helped bandage R1’s cut while waiting on the bus and that staff changed R1’s bandage upon arrival at the relocation site. R1 also stated that 2 staff from Scotts Valley changed R1’s bandage before R1 was being picked up by family on 8/22/2020.

The review of the progress notes noted that S2 responded to R1’s injury. S2 provided R1 with first aid by cleaning and bandaging the cut. R1 did not complain of pain or discomfort. Home health was arranged for R1 to receive care for the skin tear. The medical record reviewed noted R1 was virtually seen by the doctor on 8/2/2020, two days after R1 left the facility and was diagnosed with cellulitis. The skin tear was noted to be healing on follow up visit dated 8/28/2020.

This agency has investigated the complaint allegations listed. Based on interviews, review of records, the CCLD has found that the complaint allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with Nicole Bacon and a copy of the report was provided.

Page 2 of 2.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5