445294156-8-2-2024-26-AS-KHOS-D8AG27-20240819045701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:50:47 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
07/05/2024 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20240705113111

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: 130	DATE:	08/02/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Alex Baisu		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff do not ensure that resident's needs are met
Staff do not safeguard resident's personal items

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Christine Dolores and Marcella Tarin conducted an unannounced complaint investigation to deliver the findings on the above allegations. LPAs met with Executive Director Alex Baisu.

On July 5, 2024, the Department received a complaint alleging Staff do not ensure that resident's needs are met. It has been alleged that residents are missing their showers.

On July 10, 2024, LPA Monter interviewed staff S1-S6. 5 Out of 6 staff interviewed stated residents are being given showers. 6 Out of 6 staff interviewed stated staff will assist residents with their showers if a resident asks for help. S4 stated the shower schedule is very disorganized and residents have missed their showers. Staff S4 and S5 stated residents might request a different time for their shower, which throws off the schedule later that same day. S5 stated staff might not complete the showers at the exact time scheduled, but staff will ensure its completed by the end of the shift.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

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 5

Control Number 26-AS-20240705113111

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: 08/02/2024

NARRATIVE

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LPA Monter interviewed residents R1-R9. R1 stated the facility has missed giving him/her a shower. R1 stated when staff doesn’t arrive for his/her scheduled shower, he/she will contact staff, then staff will assist him/her. 2 Out of 9 residents interviewed (R3 & R8), stated they don’t need assistance with showering. 4 Out of 9 residents interviewed (R4-R7) stated they receive their showers, and the facility hasn’t missed giving his/her shower. Resident R2 and R9 were unavailable to be interviewed.

On July 5, 2024, the Department received a complaint alleging Staff do not safeguard resident's personal items. It has been alleged that resident’s laundry has been lost.

On July 10, 2024, LPA Monter interviewed staff S1-S6. Staff S1 stated the facility has a schedule for laundry service and each resident has their own bins. S1 S2 S3 S5 stated they put the residents’ cloths in the washer, and note it on the board, with the resident’s room number to keep track of their cloths. S1 S2 S5 stated the residents’ cloths has not been lost. S3 S4 S6 stated if a resident reports something lost, then the facility will replace the lost item or reimburse the resident.

LPA interviewed residents R1-R9. R1 stated the facility has lost some of his/her cloths but once he/she informs the staff, they find the missing clothing. 4 Out of 9 residents’ interview (R3, R5-R7) stated they have not had any clothing lost. Residents R4 and R8 stated they do not use the facility laundry service. Resident R2 and R9 were unavailable to be interviewed.

Based on investigation, records 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 allegations did or did not occur.

This report was reviewed with Executive Director Alex Baisu and Valentine Mathangani, Health & Wellness Director III a copy of the report was provided.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
07/05/2024 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20240705113111

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: 130	DATE:	08/02/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Alex Baisu		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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8
9

Staff are not following precautions to prevent a COVID outbreak
Staff handled resident in a rough manner
Staff do not treat resident with dignity or respect

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
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12
13

Licensing Program Analysts (LPAs) Christine Dolores and Marcella Tarin conducted an unannounced complaint investigation to deliver the findings on the above allegations. LPAs met with Executive Director Alex Baisu.

On July 5, 2024, the Department received a complaint alleging Staff are not following precautions to prevent a COVID outbreak.

On July 10, 2024, LPA Monter interviewed staff members S1-S6. 6 Out of 6 Staff stated the facility is following their infection control protocol. 6 Out of 6 staff stated the dining room is closed to prevent spread of covid. Staff S1, S5 & S6 stated the facility has PPE for rooms with covid positive residents. Staff S3 & S4 stated meals are being delivered to residents. Staff S4 & S6 stated masks are being provided to residents. S6 stated they have contacted local public health several times for guidance and are reporting covid cases to families, residents’ physicians and CCL.
PAGE 1 OF 3.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20240705113111

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: 08/02/2024

NARRATIVE

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LPA Monter interviewed residents R1-R9. Resident R1 and R3-R8 stated the facility does have an outbreak of covid. Resident R1 and R3-R7, stated the dining room is currently closed and meals are being delivered to the resident’s room. Resident R4-R5, R9 stated the facility is offering residents masks. Resident R2 and R9 were unavailable to be interviewed.

LPA Monter interviewed Witness W1. W1 stated there is currently a covid outbreak at the facility. W1 stated the dinning room is closed due to the covid outbreak.

LPA Monter toured the facility. LPA observed the dining room as closed. LPA observed the facility delivering residents lunch to residents’ bedroom. LPA observed facility staff wearing masks.

On July 5, 2024, the Department received a complaint alleging Staff handled resident in a rough manner. It has been alleged that resident R1 was pushed.

On July 10, 2024, LPA Monter interviewed staff members S1-S6. 6 Out of 6 staff interviewed denied the allegation and stated staff members don’t push residents. 6 Out of 6 staff members interviewed stated staff did not push R1.

LPA Monter interviewed residents R1-R9. R1 stated he/she has never been pushed by staff. Resident R3-R8 stated they have not seen staff pushing residents. Resident R2 and R9 were unavailable to be interviewed.

LPA Monter interviewed Witness W1. W1 stated he/she has never seen staff handle residents roughly or seen staff push residents.

On July 5, 2024, the Department received a complaint alleging Staff do not treat resident with dignity or respect. It has been alleged R1 was left at the dinning room table for an extended period of time.

PAGE 2 OF 3.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 26-AS-20240705113111

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: 08/02/2024

NARRATIVE

1
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On July 10, 2024, LPA Monter interviewed staff members S1-S6. Staff S1-S3, S5-S6, stated residents have not been left unattended in the dinning room for an extending period of time. S4 stated he/she has seen R1 left unattended. S4 stated staff don’t want to escort R1 because staff state they are going home. Staff S1-S6 stated residents are treated with dignity and respect.

LPA Monter interviewed residents R1-R9. R1 stated he/she has never been left alone, unattended in the dinning room for an extending period. Residents R3-R8 stated they have not seen residents left unattended in the dining room for an extending period. Residents R1, R3-R8 stated they are treated with dignity and respect. Resident R2 and R9 were unavailable to be interviewed.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

This report was reviewed with Executive Director Alex Baisu and
Valentine Mathangani, Health & Wellness Director III and a copy of the report was provided.

PAGE 3 OF 3.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5