445294156-3-20-2024-26-AS-KHOS-D4CR8Z-20240415124847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 03/20/2024
Date Signed: 03/20/2024 04:37:01 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
12/11/2023 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20231211110846

FACILITY NAME:	BROOKDALE SCOTTS VALLEY		FACILITY NUMBER:	445294156
ADMINISTRATOR:	KUMAR, BEENA		FACILITY TYPE:	740
ADDRESS:	100 LOCKEWOOD LN		TELEPHONE:	(831) 438-7533
CITY:	SCOTTS VALLEY	STATE: CA	ZIP CODE:	95066
CAPACITY:	220	CENSUS: 121	DATE:	03/20/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Associate Executive Director, Alex Baiasu		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not follow COVID mitigation prevention protocols
Staff do not maintain the kitchen in clean and sanitary condition
Staff did not ensure faciltiy was free of pests

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Associate Executive Director, Alex Baiasu and stated the purpose of today’s visit.

On 12/11/2023, the Department received a complaint with the above allegations. On 12/21/2023, the Department conducted an initial investigation at the facility. On 12/21/2024, LPA Rai interviewed 7 staff.

Continuation on LIC 9099-C, Page 1 of 4.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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 6

Control Number 26-AS-20231211110846

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: 03/20/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Page 2 of 4.
Staff do not follow infection control practices
In December 2023, the facility had positive cases of COVID-19 among the residents and facility staff. Per Community Care Licensing Division Provider Information Notices (PIN) 23-13-ASC, the PIN states “As the rick for transmission increases in the community, wearing a mask is an important consideration for Adult and Senior Care (ASC) facilities where higher risk individuals are present…Licensee should follow the strictest requirements.”

On 12/21/2023, the Department interviewed 7 staff at the facility. Associate Executive Director (AED) stated the Health and Wellness Director overseeing the COVID-19 procedure at the facility. Health and Wellness Director (HWD) stated the facility has reported cases on the local Public Health Department’s SPOT website and facility has been conducted mass testing of residents and staff. HWD stated they clean and sanitize the facility and staff are required to wear masks during the exposure time frame. 4 Out of the 7 staff stated the staff are required to wear a mask and staff do wear masks in the facility during exposure time frame. 1 Out of the 7 staff stated there have been incidents where more than one staff do not wear a mask in the facility, but the facility management will remind staff when observed not wearing the mask in the facility.

On 3/20/2024, LPA Rai interviewed 1 resident (R1). R1 stated he/she did observe staff wearing a mask when the facility required everyone to wear the mask for safety.

Staff do not maintain the kitchen in clean and sanitary condition
On 12/11/2023, it was alleged the kitchen is not clean and the coffee pots and kitchen machinery is not being cleaned.

On 12/21/2023, LPA observed the kitchen area with Associate Executive Director (AED). LPA observed the flooring of the kitchen area free of pests, debris and visible food particles. LPA observed kitchen appliances and coffee pots to be clean and in sanitary conditions. LPA observed coffee pots that were not in use were clean and drying on a rack.

Continuation on LIC 9099-C, Page 3 of 4.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 26-AS-20231211110846

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: 03/20/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Page 3 of 4.

On 12/21/2023, LPA interviewed the Executive Head Chef (EHC), who stated each staff in the kitchen has their areas they need to clean and there is a schedule of when and where the staff need to clean. EHC stated once the area or kitchen items are cleared, the staff need to initial to state the task has been completed. Based on record review of Cleaning Schedule for Cooks from 12/1/2023-12/20/2023, staff initials all areas of the kitchen were cleaned daily, such as ovens, fryer, grill and work stations.

Staff did not ensure facility was free of pests
On 12/11/2023, it was alleged that pests were seen in resident rooms and in the facility, such as the attic and kitchen.

On 12/21/2023, the Department interviewed 7 staff at the facility. 0 Out of the 7 staff stated there have been pests in the kitchen. 1 Out of the 7 staff stated there have been pests in the attic. 4 Out of the 7 staff stated there have been pests in the resident rooms. 5 out of 7 staff stated there have been incidents of pests in resident rooms, but management does respond in a timely manner, wherein the maintenance team will spray or set the traps.

On 12/21/2023, LPA Rai toured the kitchen with Associate Executive Director (AED) and did not observe any signs of pests and the kitchen floor was clear of any visible debris or food particles. AED stated the facility conducts extermination visits on a monthly basis. AED stated when a concern is brought up regarding pests in the facility, they will schedule a visit for exterminators to come out in addition to the monthly visits. Based on review of service Invoices for an exterminator vendor, the facility had extermination services on 11/7/2023 and 12/5/2023 and there was no pest activity found, which included mice and cockroaches.

On 12/11/2023, LPA observe at random two resident rooms and did not observe any pests, such as mice or cockroaches.

On 3/20/2024, LPA Rai observed at random two resident rooms and did not observe any pests, such as mice or cockroaches.

Continuation on LIC 9099-C, Page 4 of 4.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
12/11/2023 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20231211110846

FACILITY NAME:	BROOKDALE SCOTTS VALLEY		FACILITY NUMBER:	445294156
ADMINISTRATOR:	KUMAR, BEENA		FACILITY TYPE:	740
ADDRESS:	100 LOCKEWOOD LN		TELEPHONE:	(831) 438-7533
CITY:	SCOTTS VALLEY	STATE: CA	ZIP CODE:	95066
CAPACITY:	220	CENSUS: 121	DATE:	03/20/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Associate Executive Director, Alex Baiasu		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff retained a resident with a prohibited health condition

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 26-AS-20231211110846

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: 03/20/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Page 2 of 2.

On 12/11/2023, it was alleged that a resident with active MRSA was residing at the facility. MRSA is a bacteria which is highly infectious and cause infections in different parts of the body.

On 12/21/2024, the Department interviewed Health and Wellness Director (HWD), who stated the facility does not have a resident with a prohibited health condition. LPA reviewed California Code of Regulation 87615 Prohibited Conditions, which included inflection such as Staphylococcus aureus "Staph" and MRSA. HWD stated the facility does not have residents with active MRSA. Staff S1 and S4 stated the residents do not have MRSA. Staff S2 stated there hasn’t been a case of MRSA in the building in the last 2 year. Staff S3 stated he/she does not have knowledge of residents having MRSA.

Based on the record review of Incident Reports the facility has sent to the Department, the facility has not reported a case of MRSA in the building in the last 2 years. HWD stated there are residents that are placed in isolation due to being positive for COVID-19 and the facility staff following Infection Control guidelines.

The Department has completed the investigation of the above allegations. Based on interviews conducted and observation, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 6

Control Number 26-AS-20231211110846

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: 03/20/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Page 4 of 4.

On 3/20/2024, LPA Rai interviewed 1 resident (R1). R1 stated he/she has not observed mice, cockroaches or other pests in his/her room. R1 is not aware if pests were observed in other parts of the facility. LPA Rai observed R1's room and did not observe pests during visit.

Based on the interviews conducted with staff, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6