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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 12/21/2024
Date Signed: 12/21/2024 02:21:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2023 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230706110045
FACILITY NAME:BROOKDALE SCOTTS VALLEYFACILITY NUMBER:
445294156
ADMINISTRATOR:KAMDAR, DIMPLEFACILITY TYPE:
740
ADDRESS:100 LOCKEWOOD LNTELEPHONE:
(831) 438-7533
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:220CENSUS: 139DATE:
12/21/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:
Alex Baiasu		TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff are not keeping accurate resident records.
INVESTIGATION FINDINGS:
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According to a report from a Reporting Party (RP), the RP alleged that facility staff are inputting inaccurate information on resident's records.

Based on records review of two resident files, LPA found errors for Resident 4 (R4) and Resident 5 (R5); however, the errors do not indicate staff purposely entered the error. The RP reported that a management staff that was employed in 2023 directed staff to do such in order to cover themselves. According to an interview with the current ED, that person is no longer an employee of Brookdale Scotts Valley.

R4's Medication Administration Record (MAR) dated July of 2023 was reviewed. The MAR indicated that R4 did not receive a medication order for insulin prior to dinner on 07/03/23. According to the MAR, if a resident is given a medication, there would be a check mark along with a code number and staff initials.

Continues on LIC 9099 - C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
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 7
Control Number 26-AS-20230706110045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: BROOKDALE SCOTTS VALLEY
FACILITY NUMBER: 445294156
VISIT DATE: 12/21/2024
NARRATIVE
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Continues from LIC 9099
The staff code indicates which nurse administered the medication and the reason for entry. For 07/03/23, there was an X along with the code 09. According to the MAR legend, code 09 means "other/see nurse notes". LPA Valerio reviewed five out of five pages of nurse notes for July of 2023. LPA observed a note missing for 07/03/23 at 16:00, which does not show the reason for the missing entry. Due to this error, a person cannot determine if the resident did or did not receive the medication.

R5's MAR dated July of 2023 was reviewed. Per R5's admission agreement, R5 moved into the facility on 06/30/2023. LPA Valerio observed all regularly scheduled medications to be missing a signature indicating medications were provided to the resident. The MAR showed the resident started receiving medications on 07/04/23.

According to an interview with ED Alex, R5 moved in on 06/30/2023 and had a paper MAR until medications were interfaced by the pharmacist. If R5 moved into the facility on 06/30/23, R5 should have been given medications. According to ED Alex, R5 was not in the community from 06/30/2023 until 07/04/2023.

Based on records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.  An exit interview was conducted, and a copy of the report was left at the facility
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20230706110045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: BROOKDALE SCOTTS VALLEY
FACILITY NUMBER: 445294156
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2025
Section Cited
CCR
87465(a)(6)
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87465 Incidental Medical and Dental Care(a)... (6)... a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidenced by:
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Licensee stated Administrator will send a copy of in-service training held with staff by POC due date.
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Based on records review, the licensee did not ensure staff maintained a complete medication record for R4 and R5 medication dosages, which poses a potential health, safety, and personal rights risk to residents in care.

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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2023 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230706110045

FACILITY NAME:BROOKDALE SCOTTS VALLEYFACILITY NUMBER:
445294156
ADMINISTRATOR:KAMDAR, DIMPLEFACILITY TYPE:
740
ADDRESS:100 LOCKEWOOD LNTELEPHONE:
(831) 438-7533
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:220CENSUS: DATE:
12/21/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Alex BaiasuTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff are not providing proper wound care to residents.
Staff are not meeting residents’ diabetic care needs.
Staff do not ensure residents take medications as prescribed.
Staff did not respond to resident’s calls for help.
Staff did not prevent resident from eloping.
Staff are not meeting residents’ hygiene care needs.
Staff are not providing adequate laundry service for residents.
Staff are not providing adequate food service for residents.
Staff are not properly treating facility for pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA Valerio met with Executive Director (ED) Alex Baiasu, and explained the purpose of the visit.

The investigation consisted of records review of facility records, interviews with residents, and interviews with staff. The following has been determined as it relates to the aforementioned allegations.

Staff are not providing proper wound care to residents.

According to the RP, Resident 1 (R1), Resident 3 (R3), and Resident 4 (R4) were observed to have wounds on their body but the facility did not assist with the wounds. R1 was said to have an open sore on the resident's bottom. According to facility records for R1 in 2023, R1 was on skin checks four times per day. Based on the records, records did not indicate any open wounds and stated skin was intact.
Continues on LIC 9099 - C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 26-AS-20230706110045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: BROOKDALE SCOTTS VALLEY
FACILITY NUMBER: 445294156
VISIT DATE: 12/21/2024
NARRATIVE
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Continued from LIC 9099 - A
Resident (R3) was said to have wounds on their legs. LPA Valerio reviewed facility records for 2023. LPA reviewed a skin assessment conducted on 04/23/23. The skin assessment showed no open wounds. The facility did not have any documentation showing R3 to have wounds in 2023. R4 was said to have wounds on their skin and R4's skin was rotten. LPA Valerio reviewed facility records for R4. The facility had all records for R4, except the resident's LIC 602 (medical assessment) for 2023. Medication Administrator Records (MAR) show the resident was prescribed multiple medications used to address skin related concerns. According to an interview conducted with R4 in 2024, R4 stated they did not have any complaints against the facility.

Staff are not meeting residents’ diabetic care needs / Staff do not ensure residents take medications as prescribed.

According to the RP,  residents were neglected to have their blood sugar checked by facility staff on 07/03/2023 and 07/04/2023. LPA Valerio requested facility documentation for two (2) residents present in 2023 that needed to have their blood sugar checked prior to meal. According to MAR for R4, there was a physician order to have R4's blood sugar checked twice a day at 0800 and 2000 hours. Based on records review, the resident had their blood sugar checked at each time during both dates.  LPA  Valerio reviewed facility records for Resident 5 (R5). According to MAR for R5, R5 did not have an order to have blood sugar checks until 07/06/2023.

Staff did not respond to resident’s calls for help.

According to the RP. Resident 6 (R6) experienced a fall, pressed their call light, and staff did not respond all night. Based on records review, the R6 had a documented fall on 07/04/2023 and did not suffer a fall on any other date. LPA Valerio requested a copy of the unusual incident report submit for R6 along with a copy of R6's personal residential care plan. The facility was unable to produce these documents; therefore, no additional information could be obtained. According to Executive Director Alex Baiasu, the resident had one fall with no injuries and the no unusual incident report was required to send unless it involved hospital transfers.

Continues on LIC 9099 - C, Page 3...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20230706110045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: BROOKDALE SCOTTS VALLEY
FACILITY NUMBER: 445294156
VISIT DATE: 12/21/2024
NARRATIVE
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Staff did not prevent resident from eloping.
According to the RP, a resident in room number 409 had eloped from the building and was found on the ground in the parking lot located in the front of the facility. LPA Valerio requested resident information for the resident who was present in 2023. According to Executive Director Alex, Resident 7 (R7) occupied the room 2023. Based on records review, R7 did not have a documented elopement in 2023.

Staff are not meeting residents’ hygiene care needs.
According to the RP, R7 did not receive a shower after being found outside on the ground. According to Ed Alex, the facility does not document whether a shower was given or not. Residents are provided a shower schedule, if they receive assistance from staff. If a staff member does not get to the resident's shower or the resident refuses to shower for the day, there would not be a document for review.

Staff are not providing adequate laundry service for residents.
According to the RP, the facility allegedly did not provide residents with clean clothing. According to an interview with Staff 1 (S1), S1 does not recall any issues with laundry or laundry machines during 2023. According to an interview with R5, R5 had no complaints for the facility, always has clean item to wear, and stated housekeeping is at the facility every day.

Staff are not providing adequate food service for residents.
According to the RP, the facility did not have enough staff resulting in residents not getting their meals. On 07/05/23, it was alleged that meal service took so long that residents left the dining room without eating.

According to an interview with staff, staff stated service staff are separate from clinical staff. If there are any shortages with service staff, there are multiple back-ups, such as on-call servers or any administrative or management staff that would be able to provide service. Interviews with staff also indicate that they never observed any shortage of wait staff and to their knowledge every resident received their food.
Based on interviews with six (6) resident interviews, 6 out 6 resident interviews stated that food had always been delivered on time, have never received cold food, or did not have any issues with the food at the facility.

Continues on LIC 9099 - C, Page 4...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20230706110045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: BROOKDALE SCOTTS VALLEY
FACILITY NUMBER: 445294156
VISIT DATE: 12/21/2024
NARRATIVE
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Staff are not properly treating facility for pests.

According to the RP, the facility is alleging that the facility had rodents in the kitchen and left it untreated, which contributed to a norovirus outbreak in 2023.

Based on review of facility records, the facility contracted pest control services through EcoLab. The facility provided copies of services provided on 07/05/23, 07/12/23, 07/13/23, 07/25/23, 08/15/23, 08/24/23, 09/14/23, and 09/20/23. All services, which included inspections and placement of traps, addressed rodent issues throughout the facility
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Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held, and a copy of report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7