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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 03/20/2024
Date Signed: 03/20/2024 04:38:25 PM

Unfounded


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
12/15/2023 and conducted by Evaluator Simranjit Rai
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20231215162348
FACILITY NAME:BROOKDALE SCOTTS VALLEYFACILITY NUMBER:
445294156
ADMINISTRATOR:KUMAR, BEENAFACILITY TYPE:
740
ADDRESS:100 LOCKEWOOD LNTELEPHONE:
(831) 438-7533
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:220CENSUS: 121DATE:
03/20/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Associate Executive Director, Alex BaiasuTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility did not monitor resident's declining health condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Associate Executive Director, Alex Baiasu and stated the purpose of today’s visit.

On 12/15/2023, the Department received a complaint with the above allegations. On 12/21/2023, the Department conducted an initial investigation at the facility. On 12/23/2024, LPA Rai interviewed 7 staff.

Continuation LIC 9099-C, Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (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 2
Control Number 26-AS-20231215162348
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
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Page 2 of 2.

On 11/20/2023, R1 complained of shortness of breathe and was placed on oxygen to improve O2 saturation.
On 11/21/2023, R1 had an unwitnessed fall where R’s foot got tangled in the footrest of their electric wheelchair. No injured, bruise or skin tears. Paramedics were called via 911 and determined she was uninjured, and resident declined to go to ER. On 11/22/2023, R1 was confused and was taking new antibiotics for UTI where confused can be a symptom of the medication. On 11/23/2023, R1 refused medication, was feeling nauseous and weak and did not have congestion. R1 vomited right before being transported to the hospital. R1 was admitted to the hospital due to testing positive for COVID-19.

Based on review of R1’s records, R1 was being monitored for any changes at the facility from 11/01/2023 to 11/23/2023, when R1 was transported to the hospital. Per R1’s Progress Notes, Medication Technician (Med-Tech) and Nursing staff (LVN, LPN, RN) documented R1’s change of condition, medication administration and medication concerns every day.

On 11/21/2023, the Department interviewed staff (S1), a caregiver for R1. S1 stated before being admitted the hospital, R1 used oxygen and was not uncommon for resident to complaint about shortness of breath. S1 stated the staff did advise R1 to go to the hospital but R1 would refuse.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, 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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (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 2