445294156-5-16-2024-26-AS-RMAO-D5QPVV-20240529113946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 05/16/2024
Date Signed: 05/16/2024 10:52:59 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
03/19/2024 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20240319114814

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):

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Facility staff coerced resident to pay for additional services.

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

On 3/19/2024, the Department received a complaint with the above allegation. On 3/19/2024, the Department conducted an initial investigation at the facility. It was alleged the facility is forcing R1 to pay for medication administration when R1 is able to manage medication.

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)

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Control Number 26-AS-20240319114814

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

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Page 2 of 2.
On 3/20/2024, LPA Rai interviewed 2 staff. S1-S2 stated R1 is not capable to manage his/her own medication, therefore the facility staff will manage the medication and R1 will see the charge on the invoice. S1 and S2 stated R1 does not take the medication prescribed by the physician, sometimes its by choice or R1 is not aware of taking the medication. S1 stated R1 was admitted to the hospital and skilled nursing facility for more than a month and R1 was being provided the medication during the stay. S2 stated the facility staff are working with R1’s primary care physician and physician has agreed with resident needing assistance with medication management. S2 stated R1 has been assessed and R1 has not demonstrated that the resident can management medication.

Based on record review of R1’s Physician’s Report dated 8/29/2023 and 3/12/2024, R1 was assessed, and physician reported R1 is not able to administer own prescription and PRN medications. Based on review of R1’s Self Administration of Medication review dated 3/14/2024, R1 is unable to identify the expiration date of each medication, state what each medication is for, state what time medications are to be taken, state the proper dosage for each medication. Based on R1’s Progress Note for 3/15/2024, R1 had an appointment with R1’s primary care physician who order R1 to stay on medication management. Based on the records, R1 is not able to manage medications and facility staff will need to assist R1.

On 5/16/2024, LPA Rai interviewed R1. R1 stated he/she recalls the HWD and the primary care physician speaking with him/her regarding the medication management. R1 stated he/she is aware of the facility adding the medication management charges and did not feel like it was coerced, but R1 would like to manage the medications on his/her own. R1 did not recall the assessment questions, but understands why the facility and primary care physician may want the facility staff to manage the medications on his/her behalf.

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)

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