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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294156
Report Date: 08/25/2021
Date Signed: 08/25/2021 03:46:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BROOKDALE SCOTTS VALLEYFACILITY NUMBER:
445294156
ADMINISTRATOR:EDWARDS, ANTONETTEFACILITY TYPE:
740
ADDRESS:100 LOCKEWOOD LNTELEPHONE:
(831) 438-7533
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:220CENSUS: 134DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Nicole BaconTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced annual inspection today and met with Executive Director (ED) Nicole Bacon.

LPA entered the facility through designated central point of entry and was screened by staff. LPA observed staff screen visitors and residents. COVID-19 postings were observed in the hallways and common areas. Staff, residents in common areas, and visitors were observed to be wearing face coverings. Hand sanitizers, soap, and paper supplies were observed to be available. At least 30 days' supply of personal protective equipment (PPE) were available in the premises.

LPA toured the facility with Maintenance Director Junior Zavala. LPA toured 2 dining rooms, maintenance room, library, activities office, kitchen, theater, bingo room, 2 facility courtyards, and 10 resident bedrooms. Temperature observed between 71*F and 85* F. Facility water temperature measured between 113.7*F and 119.6*F.

Per Administrator, the facility is currently accepting visitors inside the facility, including residents' bedrooms. The facility has reached a 76.9% and 54.6% COVID-19 vaccination rate for residents and staff respectively. Facility has resumed surveillance testing for staff weekly. The facility's weekly activity schedule was reviewed and included exercises, craft classes, games, and musical activities. The facility's COVID-19 mitigation plan has been reviewed and is still in place.

No deficiencies were cited. Exit interview conducted with Administrator and a copy of this report was provided during visit.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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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