445294156-12-21-2024-26-AS-KHOS-DCVK5M-20250113063606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 12/21/2024
Date Signed: 12/21/2024 02:25:57 PM

Unsubstantiated

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
12/22/2023 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20231222164321

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: 139	DATE:	12/21/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Alex Baiasu		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Facility staff are not responding to resident's call system in a timely manner.
Facility does not have sufficient staff to meet the needs of residents.
Facility staff are not ensuring that resident’s colostomy care is being addressed.

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

According to the Reporting Party (RP), the facility does not respond to call lights in a timely manner due to short staffing. There was an incident with Resident 1 (R1) where R1''s colostomy bag exploded because staff did not change the bag.

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: 1 of 3

Control Number 26-AS-20231222164321

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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LPA Valerio reviewed progress notes for R1. R1 was admitted to the facility on 11/24/23. During admission, the staff on shift notes that R1's Colostomy bag was leaking. The staff emptied and replaced the bag. According to the staff, the staff educated family and caregiver on emptying colostomy bag and advised to call nurse for assistance when needed. Based on R1's records, R1 had home health services, which included visiting nurses for nephrostomy care. R1 was sent to the hospital by the facility on 11/25/23 at 5:30 AM due to R1's family member observing the bag to explode and the family member did not have supplies to change it. R1 did not return to the facility and was only at the facility for less than 24 hours.

According to an interview with Staff 1 (S1) the facility call logs are not available past 6 months. Anything before that the third party contractor may or may not be able to retrieve the information.

According to the RP, Resident 2 (R2) had been reporting rats being seen and although facility maintenance staff put a rat trap in the room, R2 attempted to catch the mouse, which resulted in a fall. According to the RP, the facility failed to respond to R2 call for help. LPA Valerio reviewed facility records for R2. R2 was observed to have a fall on 11/14/2023. R2 was found by staff after they heard a loud thump. R2 stated, "I was trying to catch the mouse in my apartment, lost my balance, and fell back dropping the cat food. While falling down I hit my head on the floor and landed on my right wrist." Facility staff immediately contacted 911, checked resident vitals, and was sent to the hospital shortly after. Based on records review, the residents current assessment now have a fall risk in place. The latest assessment was conducted on 10/04/2024.

According to an interview with Resident 3 (R3), R3 feels that staff have always been attentive to their needs. R3 cannot recall how last year (2023) was entirely but nothing came to mind. R3 reports that there are many staff that are working all the time.

According to an interview with Resident 4 (R4), R4 likes living at the facility and has been at the facility for thirteen years. R4 reported staff assist resident when R4 needs assistance with toileting. Anytime R4 calls for help, staff are there to assist R4.
Continues on LIC 9099 -C...

On 01/04/2024, this report was amended to remove irrelevant information and confidential pronouns.

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 3

Control Number 26-AS-20231222164321

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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LPA Valerio reviewed the December Staff Schedule for 2023. LPA observed the facility scheduled a minimum of two Medication Technician (MT)s and three Caregivers (CG) for AM shift (6:00 AM - 2:00 PM) and PM Shift (2:00 PM - 10:00 PM). During overnight shift, there was one MT and two CG scheduled. LPA observed that on 12/04/23 and 12/05/23, there was a call out and therefore only two caregivers were on shift for the PM shift. On 12/09/23, the facility had two caregivers call out that day and therefore, there was only one CG on shift along with two MTs. On 12/13/2023, LPA observed one CG staff call out leaving only two MTs and two CGs on shift for the AM shift. For the week of 12/17 - 12/23, the facility had scheduled a minimum of two MT and three CG on all shifts. On 12/24/2023 and 12/23/2023, they had scheduled an extra LVN and caregiver for this shift, which left the facility with three MTs and four CGs during PM shift. For 12/23/23 - 12/31/23, LPA Valerio two MT and three CG on each shift for AM. For PM shift, they scheduled three MT and three CG.

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)

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