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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294156
Report Date: 05/03/2024
Date Signed: 05/03/2024 01:54:02 PM


Document Has Been Signed on 05/03/2024 01:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VALLEYFACILITY NUMBER:
445294156
ADMINISTRATOR:KUMAR, BEENAFACILITY TYPE:
740
ADDRESS:100 LOCKEWOOD LNTELEPHONE:
(831) 438-7533
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:220CENSUS: 126DATE:
05/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Momo DuoaTIME COMPLETED:
02:00 PM
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On May 3, 2024, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management-Incident visit regarding a SOC341 that was sent to the Department. LPA met with Administrator Momo Duoa and explained the purpose of the visit.

On April 30, 2024, the Department received a SOC341 reporting allegations of psychological abuse from staff S1-S4.

LPA interviewed resident R1 and ADM.
LPA requested staff S1-S4 LIC501 and training documents. LPA also requested a copy of videos as well.
LPA requested a copy of R1's physician's report, needs and service plan and emergency contact form.

This incident requires further investigation. This report was reviewed with Administrator Momo Duoa and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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