445294156-5-3-2023-26-AS-KHOS-CSHK6Q-20230605073756

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 05/03/2023
Date Signed: 05/03/2023 05:58:40 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2023 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20230420120248

FACILITY NAME:	BROOKDALE SCOTTS VALLEY		FACILITY NUMBER:	445294156
ADMINISTRATOR:	KAMDAR, DIMPLE		FACILITY TYPE:	740
ADDRESS:	100 LOCKEWOOD LN		TELEPHONE:	(831) 438-7533
CITY:	SCOTTS VALLEY	STATE: CA	ZIP CODE:	95066
CAPACITY:	220	CENSUS: 118	DATE:	05/03/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Jayden Bettencourt		TIME COMPLETED:	06:02 PM

ALLEGATION(S):

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Staff did not prevent the spread of a stomach virus
Staff did not prevent a rodent infestation
Facility dishwasher is in disrepair
Staff are are not providing adequate food service for residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced complaint investigation at the facility regarding the above allegations, LPA met with facility Assistant Executive Director Jayden Bettencourt (Admin).

LPA toured the facility, interviewed 10 residents and 7 staff, and reviewed facility extermination records. dishwasher repair invoice, facility menu, and reports from outside regulatory agencies. During tour of the facility, LPA did not observe any evidence of a rodent infestation.

During tour of the facility kitchen, LPA observed the dishwasher to be functioning properly. 2 out of 2 kitchen staff interviewed stated that the dishwasher had been broken on 03/30/2023, and was non operational for 1 day, but was repaired the next day. Review of dishwasher repair invoice confirmed that the dishwasher was repaired on 03/31/2023.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230420120248

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: BROOKDALE SCOTTS VALLEY	FACILITY NUMBER: 445294156
	VISIT DATE: 05/03/2023

NARRATIVE

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During interviews with facility staff and residents, 10 out of 10 residents interviewed stated that they had never noted a rodent or pest infestation at the facility. 1 out of 10 residents stated that they had seen a rat in the facility at one time, but that they had never noticed an infestation of any pest. 9 out of 9 staff interviewed stated that they were unaware of pest infestations at the facility and had not witnessed pests in the facility.

10 out of 10 residents interviewed stated that the food provided by the facility had variety, and that the facility had been following it's weekly menus during the Norovirus outbreak at the facility. 7 out of 10 residents stated that the food was delivered in a timely manner, 3 out of 10 residents delivered stated that food delivery was slow during the lock down. 1 out of 10 stated that the food was good, but arrived cold by the time it was delivered to him.

LPA interviewed a witness (W1) from a separate regulatory agency that conducted an inspection during the facility's Norovirus outbreak. W1 stated that the facility was adhering to most of its best practices and infection control policies during inspection of the facility. W1 stated that there were not enough hand washing stations between rooms in the facility for staff to wash their hands between visits to resident rooms. W1 stated that there was also not enough signage posted in the facility to alert staff, visitors, and residents to Norovirus best practices. W1 stated that other than those two suggestions, the facility adhered to all other infection prevention guidelines, and had implemented W1's suggestions in a timely manner. Review of report from outside regulatory agency was reflective of W1's statements.

This Department has investigated the above allegations. Based on observation, interviews and records review, the Department has determined that the allegations are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

This report was reviewed with Assistant Executive Director Jayden Bettencourt and a signed copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC9099 (FAS) - (06/04)

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