445294156-4-24-2024-26-AS-JJIN-D6KVFP-20240625162417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 04/24/2024
Date Signed: 04/24/2024 07:33:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/05/2021 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210105093442

FACILITY NAME:	BROOKDALE SCOTTS VALLEY		FACILITY NUMBER:	445294156
ADMINISTRATOR:	HARRISON, PAUL		FACILITY TYPE:	740
ADDRESS:	100 LOCKEWOOD LN		TELEPHONE:	(831) 438-7533
CITY:	SCOTTS VALLEY	STATE: CA	ZIP CODE:	95066
CAPACITY:	220	CENSUS: 129	DATE:	04/24/2024
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Momo Duoa		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff not meeting residents care needs
Resident not administered medication as prescribed

INVESTIGATION FINDINGS:

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On 4/24/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint inspection. LPA met with Executive Director, Momo Duoa and explained the purpose of the visit.

During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility.

On 01/05/2021, the Department received a report alleging that staff not meeting residents care needs and resident not administered medication as prescribed.

The Department conducted interviews and record reviews. Based on the information available, it was unable to prove whether staff were not meeting residents care needs and resident was not administered medication as prescribed.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated, at this time.

No deficiencies were cited during the visit. Report is reviewed and copy is provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

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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