445294156-5-16-2024-26-AS-RMAO-D5QQ6W-20240529115412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 05/16/2024
Date Signed: 05/16/2024 10:52:16 AM

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
03/13/2024 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20240313160527

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: 119	DATE:	05/16/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Health and Wellness Director, Valentine Mathangani		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee is charging resident for services not provided

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 Health and Wellness Director, Valentine Mathangani and stated the purpose of today’s visit.

On 3/13/2024, the Department received a complaint with the above allegation. On 3/13/2024, the Department conducted an initial investigation at the facility. It was alleged resident (R1) was paying for care services while out of the facility and admitted to the hospital.

On 12/12/2023, R1 was taken the hospital due to a health concern. R1 was admitted to a skilled nursing facility after hospital discharge and did not come back to the facility. R1’s belonging are in the room, as well as R1’s spouse currently residing in the room.

Continuation on LIC 9099-C, Page 1 of 2.

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: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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-20240313160527

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: 05/16/2024

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 3/20/2024, LPA Rai interviewed AED, Alex Baisu and 2 staff (S1-S2). AED and S1 confirmed R1 is not in the community during today’s visit and R1 is admitted at the skilled nursing facility. AED, S1 and S2 stated R1’s belongings are present at the facility and is expected to pay the invoice. AED and S1 stated the invoice will state the care services, but after 14 days, the system will reimburse the charges due to resident being out of the facility. S1 stated the facility is not requesting for the resident to pay for care costs since they are not providing the care to R1, but the Admission Agreement states the residents need to pay for the rent while they are away from the facility.

On 3/20/2024, LPA Rai interviewed R1’s spouse (R2) who resides in the same room as R1. R2 confirmed R1 has not been in the community since 12/12/2023. R2 stated he/she understands the rent agreement in where R1 will be charged the Basic Service Rate, but does not understand if the facility should charge for the Personal Service Rate.

Based on review of R1’s Admission Agreement on page 7 under “C. Absence, section 2. Fees During Absence”, it stated “if you are absent from the Community for any reason, such as, for a hospitalization, vacation, temporary nursing home care or rehabilitation, the Residency agreement will remain effective and you will be charged the full Monthly Service Rate.” The Admission Agreement is signed by R1’s Financial Power of Attorney. Based on review of R1’s Amount History Report dated 3/20/2024, R1 was charged the Personal Service Rate of on 01/01/2024, 02/01/2024, 3/1/2024 and 4/1/2024. However, R1 was credited the "Care Credit - One Time" on 2/15/2024, 3/14/2024, and again on 3/14/2024.

As indicated by AED and S1, the billing system did reimburse R1 for the care services after 14 days since R1 was out of the facility. The facility did reimburse R1 in a timely manner in February, and twice in March.

The Department has completed the investigation of the above allegation. Based on interviews conducted and record reviews, the department has found that the above allegation was 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 Health and Wellness Director, Valentine Mathangani 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: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2