445294156-8-2-2024-26-AS-KHOS-D8JMYZ-20240827100223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:55:45 PM

Substantiated

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
07/01/2024 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20240701152918

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:	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 leaves residents soiled for extended periods of time

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Christine Dolores and Marcella Tarin arrived unannounced to deliver the finding of the above allegations. LPAs met with Executive Director Alex Baisu.

On 07/01/2024, the Department received the complaint. On 07/10/2024, the initial complaint investigation was conducted.

The following documents were obtained for this investigation to include the resident roster, staff roster, staff schedule, 2 resident's physician's report, service plan, progress notes, face sheet, and medication administrator record (MAR).

PAGE 1 OF 2.

Substantiated

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 6

Control Number 26-AS-20240701152918

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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It was alleged that staff (S3) left a resident (R3) soiled for an extended period of time.

On 07/10/2024, 7 residents, 6 staff members, and 1 witness were interviewed.

Based on staff interview, after a shift change staff (S4) observed R3 was left in double diapers with both diapers filled with R3’s stool. It was stated that the AM shift caregiver left R3 in soiled double diapers since the morning.

The review of records show that on 05/28/2024 care staff documented their observation of R3 being left in dirty double diapers with stool from the AM shift.

The Department has investigated the above allegation and the preponderance of evidence standard has been met, therefore, the above allegation is SUBSTANTIATED. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D.

This report was reviewed with Executive Director, Alex Baisu and a copy of the report and appeal rights were 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 6

Control Number 26-AS-20240701152918

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/03/2024 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee states the topic of incontinence care will be provided during all-staff meetings going foward. Licensee will provide the incontinence care training from 07/26/2024 and statement of understanding of the section cited today to LPA Dolores via email by POC due date.
	8 9 10 11 12 13 14	Based on interview, record review and observation the licensee did not ensure resident (R3) was left clean and dry as R3 was found in dirty double diapers which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
07/01/2024 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20240701152918

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 handles residents in a rough manner
Staff yells at residents in care
Staff does not ensure resident’s medications are administered

INVESTIGATION FINDINGS:

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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: 4 of 6

Control Number 26-AS-20240701152918

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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Staff handles residents in a rough manner
It was alleged that staff (S1) handled resident (R1) in a rough manner by squeezing R1’s arm when transferring. It was alleged that R1 stated they were hurting and S1 would yell stating he/she is not doing anything.

On 07/10/2024, 7 residents, 6 staff members, and 1 witness were interviewed.

Based on staff interviews, a staff (S2) witnessed S1 squeeze R1’s arm during a transfer. S2 states that he/she did not believe S1’s intention was to hurt R1. S2 states R1 was not hurt and did not observe any bruises on R1 after the incident. 4 out of 6 staff denied the observation of a staff squeezing R1’s arm. 1 out of 6 staff states to have heard of this incident occurred from another staff member.

Based on resident interview, R1 did not think S1 squeezed his/her arm when assisting him/her during a transfer. It was stated that staff treats R1 nicely and none of the staff has hurt him/her.

6 out of 7 residents denied staff handling them in a rough manger. 6 out of 7 residents denied the observation of staff handling other residents in a rough manner.

1 out of 7 residents stated that sometimes the new staff are a little rough when handling R2’s care needs. R2 was unable to provide names of the staff and dates of when these incidents occurred.

Based on witness interview, W1 denied observing staff handle residents in a rough manner.

Staff yells at residents in care
It was alleged that staff (S1) yells at resident (R1). It was also alleged that staff (S3) yells at the residents.

On 07/10/2024, 7 residents, 6 staff members, and 1 witness were interviewed.

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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: 5 of 6

Control Number 26-AS-20240701152918

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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Based on resident interviews, R1 denied staff yelling at him/her. It was stated that staff treats R1 nicely and none of the staff has hurt him/her.

7 out of 7 residents denied staff yelling at the residents. 7 out of 7 residents denied the observation of staff yelling at other residents.

Based on staff interviews, 6 out of 6 staff members denied the observation of staff yelling at the residents.

Staff does not ensure resident’s medications are administered
It was alleged that staff (S3) does not ensure R3’s medications are administered and it was alleged that the resident’s medication was found on the resident’s floor.

On 07/10/2024, 7 residents, 6 staff members, and 1 witness were interviewed.

Based on resident interview, 4 out of 7 residents does not have medication management. 3 out of 7 residents interviewed has medication management. 3 out of 3 residents state the staff administers their medications daily. 3 out of 3 residents denied issues or concerns regarding their medication administration.

Based on staff interview, 6 out of 6 staff state the residents are being administered their medications. 6 out of 6 staff denied the observation of seeing loose medication on the floor.

On 07/10/2024, LPA Dolores audited R3’s medication with staff. Based on observation, R3’s medications are being administered per doctor’s orders.

The Department has investigated the above allegations. Based on interview, record review, and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Alex Baisu and
Valentine Mathangani, Health & Wellness Director III 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: 6 of 6