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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294156
Report Date: 08/13/2024
Date Signed: 08/13/2024 11:22:23 AM


Document Has Been Signed on 08/13/2024 11:22 AM - 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: DATE:
08/13/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Alex BaiasuTIME COMPLETED:
11:30 AM
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On August 13, 2024, the Department conducted an informal meeting with Administrator (ADM) Alex Baiasu and District Director of Operations Grace Ndomo, in Community Care Licensing office, to further discuss the incident regarding physiological abuse which was reported to Community Care Licensing on April 30, 2024. A Subsequent Case Management visit was conducted on May 3, 2024.

LPA and LPM requested the facility ADM provide an action plan to discuss the following:
Training regarding personal rights for all staff, from an outside vendor.
How facility staff will handle residents with MCI (Mild Cognitive Impairment).
How the facility will respect the residents personal rights
Reassessing residents to ensure, residents with MCI needs are being met.

ADM stated he will send the action plan by August 27, 2024.

LPA and LPM also discussed the use of surveillance camera's in the facility.

LPA and LPM informed ADM the facility will have more frequent monitoring as well.

This Report was reviewed with ADM Alex Baiasu and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 712-2018
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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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