445294156-6-20-2023-26-AS-KHOS-CU3JJA-20230725070512

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 06/20/2023
Date Signed: 06/20/2023 02:53:27 PM

Substantiated

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
03/17/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20210317090424

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: 127	DATE:	06/20/2023
		UNANNOUNCED	TIME BEGAN:	01:43 PM
MET WITH:	Beena Kumar		TIME COMPLETED:	02:57 PM

ALLEGATION(S):

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Staff not informing resident(s) when food is delivered.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced complaint investigation regarding the above allegation. LPA met with facility Administrator Beena Kumar (Admin).

LPA interviewed residents living in the facility on 05/06/2021. 4 out of 4 residents interviewed indicated that food was delivered into the room by staff. Residents reported that staff knocks on the doors to their rooms, enter upon resident approval, and place food inside the room. This process was confirmed to LPA by then facility Business Office Manager Elizabeth Reynaga.

Continued in 9099-C

Substantiated

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: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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-20210317090424

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: 06/20/2023

NARRATIVE

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During a tour of the facility on 06/17/2021, at 3:23pm, LPA observed a covered plate of food sitting outside of a resident's room. Upon lifting the cover, LPA observed a plate of breakfast food that was cold and untouched. LPA interviewed facility resident (R1) who lived inside of the room that food was found outside of. R1 stated that staff did not inform them upon delivery of breakfast. LPA asked resident if staff usually delivers food into the room, R1 stated that they did.

The Department has conducted an investigation of the above allegation. Based on LPA's observation, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiency cited. See LIC 9099-D. Exit interview conducted with Administrator Beena Kumar. A copy of this report, along with the facility's appeals rights were provided electronically due to printer error.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210317090424

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/27/2023 Section Cited CCR 87555(b)(1)	1 2 3 4 5 6 7	87555 - General Food Service Requirements - (1) Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	POC has already been corrected. No further action by the facility necessary,
	8 9 10 11 12 13 14	Based on observation and interviews, the facility did not ensure R1 was aware of breakfast delivery. This posed a potential risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC9099 (FAS) - (06/04)

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