445294156-12-6-2024-26-AS-KHOS-DC2TBH-20241217133509

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 12/06/2024
Date Signed: 12/06/2024 05:12:39 PM

Unsubstantiated

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
02/12/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20240212124552

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: 140	DATE:	12/06/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Alex Baiasu		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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A non-medical skilled professional is administering insulin injections to diabetic residents.
Staff are not administering residents’ insulin as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Executive Director (ED) Alex Balasu.

On 2/12/2024, the Department received a complaint with the above allegations.

On 2/22/2024, the Department conducted an initial investigation visit.

LPA interviewed ED, 3 staff, and 4 residents.

LPA requested roster of residents, LIC500, resident physician reports, Medication administration records, centrally stored medication log, resident assessment, and physician orders.

Continue on LIC9099-C. Page 1 of 4.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

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 4

Control Number 26-AS-20240212124552

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: 12/06/2024

NARRATIVE

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A non-medical skilled professional is administering insulin injections to diabetic residents:
The allegation is that a staff who is not a nurse and administers insulin injection to resident.

On 2/22/2024, LPA interviewed previous Executive Director (PED). PED stated he/she just started to work for the facility in January 2024. PED stated the facility checks the nurse license when the facility hires nurse and the facility nurse should maintain the valid nurse license. PED printed out the evidence of staff S1 and S2's nurse licenses. ED stated if residents can inject insulin by themselves, then Med Techs or nurses deliver the insulin and the residents inject the insulin by themselves. PED stated if the residents cannot inject insulin by themselves, then the facility nurses deliver the insulin and inject insulin for residents. PED stated only facility nurses can inject insulin for residents, caregivers and Med Techs were not allowed to inject insulin for residents.

LPA interviewed staff S2. S2 stated the facility checked his/her LVN license before the facility hired him/her. S2 stated Med Techs and facility nurses deliver medications to residents, but only the facility nurses deliver and inject insulin for residents. S2 stated he/she checked the computer for residents' prescription. S2 stated he/she usually deliver and inject the fast-acting insulin 30 minutes before the meals and one and half hours before bedtime for the long-acting insulin. S2 stated he/she follows the doctor orders which specifies exactly what to administer insulin to residents..

LPA interviewed 2 Med Techs. 2 Out of 2 Med Techs stated they don't conduct the insulin injection for residents.

LPA interviewed 4 residents (R1 - R4). 2 Out of 4 residents stated they don't have insulin injection. Resident R1 stated only facility nurses conducted insulin injection for him/her. R1 stated staff S1 and S2 conducted insulin injection for him/her. Resident R2 stated only facility nurses conducted insulin injection for him/her. R2 was unable to remember the names of the facility nurses.

On 9/27/2024, LPA interviewed staff S1. S1 stated he/she was in nursing school and had the permit to do the duty of facility nurse when shadowed with other facility nurses. S1 stated he/she will have LVN license next month. S1 stated he/she submitted his/her permit to the facility. S1 stated he/she only did insulin injection with nurses.
Continue on LIC9099-C. Page 2 of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20240212124552

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: 12/06/2024

NARRATIVE

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Based on the review of R1 and R2's physician report, R1 and R2 are unable to conduct injection by themselves.

Based on the checking of the S1's nurse license document, S1's LVN license was issued on 10/22/2024.

Staff are not administering residents’ insulin as prescribed:

The allegation is that resident R1 and R2 have been times residents have not received their insulin.

On 2/22/2024, LPA interviewed previous Executive Director (PED). PED stated the facility administer insulin to residents based on doctor prescription/order.

LPA interviewed staff S2. S2 stated the facility nurses deliver insulin to residents. S2 stated if residents are able to inject insulin self then residents inject insulin by self, if residents unable to inject insulin by self then nurses inject insulin for the residents.

S2 stated he/she delivers/injects insulin based on the doctor prescription in the computer system. S2 stated usually he/she delivers/injects short acting insulin 30 minutes before meals and long acting insulin one and half hours before bed time for residents. S2 stated she always sticks to doctor prescription/orders to administer insulin to residents..

LPA interviewed resident R1 and R2. Both stated they did not have experience of medication error or missing medication incidents.

Based on the review of R1 and R2 Medication Administration Records (MAR) in January 2024 and February 2024, there are some entries were observed missing insulin injections for R1.

PED and staff S2 explained the empty entries were due to computer error and staff were unable to enter data in the computer MAR system.

Continue On LIC9099-C. Page 3 of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20240212124552

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: 12/06/2024

NARRATIVE

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Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

No citations noted for today’s visit. Exit interview was conducted with ED. A copy of this report was provided to ED.

Page 4 of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4