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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294156
Report Date: 08/15/2024
Date Signed: 08/15/2024 04:55:13 PM


Document Has Been Signed on 08/15/2024 04:55 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: 125DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH: Administrator, Alex Baiasu TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Simi Rai and Marcella Tarin conducted an unannounced Required 1 Year visit. LPAs met with Administrator Alex Baiasu and stated the purpose of today's visit.

During visit, LPAs toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPAs Rai and Tarin toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPAs observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPAs toured at random 10 resident bedrooms. 10 out of 10 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from between 110 degrees F and 117.1 degrees F.

Fire extinguisher was observed and inspected on 12/05/2023. Facility smoke detectors, carbon monoxide detectors and sprinklers were inspected by a third party vendor on 08/05/2024 and passed inspection. The last disaster drill were conducted on 07/26/2024.

LPAs reviewed facility records for 10 staff and 10 residents. LPAs reviewed S1 staff file and observed S1 did not have a California Criminal Record Clearance. Administrator stated S1 did not obtain a California Criminal Record Clearance after turning 18 years of age in June 2024. Administrator will ensure S1 obtains a California Criminal Record Clearance before returning to work.

Continuation on LIC809-C, Page 1 out of 2.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 08/15/2024 04:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2024
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
This requirement is not met as evidenced by:
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Administrator stated to submit a written plan of action understanding regulation and will ensure staff obtain a California Criminal Record Clearance prior to working at the facility. Administrator will ensure staff S1 obtains a California Criminal Record Clearance by POC due date.
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Based on record review and interview, staff S1 did not have a California Criminal Record Clearance and ADM stated S1 did not obtain a Criminal Record Clearance after turning 18 years of age which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Administrator agreed and understood.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/15/2024
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Page 2 out of 2.

Deficiencies were cited per California Code of Regulations, Title 22. Technical Violation were provided during visit.

A civil penalty is being assessed for the amount of $500. For S1 working in the facility for more than 5 days without obtaining a California criminal record clearance, the civil penalty will be for $500 ($100 per day x 5 days = $500). See LIC421BG.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Administrator Alex Baiasu and a copy of the report was provided. Appeal Rights was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3