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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 08/16/2024
Date Signed: 08/16/2024 11:09:46 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/11/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230711095753
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: 125DATE:
08/16/2024
UNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Alex BaisuTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not give resident's records to resident's responsible party.
Staff did not follow resident's care plan.
Staff did not give resident sufficient notice of rate and services increases.
INVESTIGATION FINDINGS:
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On 8/16/2024 , Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director Alex Baisu and explained the purpose of today's visit.

Regarding the allegation of Staff did not give resident's records to resident's responsible party, reporting party (POA1) stated that on March 20, 2023, POA1 requested residents' (R1) medical records and medication to be delivered on move out day. Only R1s medications were handed over after a second request at the facility, and no medical records were ever given.

The Department received a copy of the email sent from POA1 to the facility Administrator at the time (ADM1) on 05/13/2023 stating POA1 requests to have the facility provide R1’s records to POA1 on 05/20/2023, the date POA1 was planning to move R1 out of the facility.

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Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
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-20230711095753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA
FACILITY NAME: BROOKDALE SCOTTS VALLEY
FACILITY NUMBER: 445294156
VISIT DATE: 08/16/2024
NARRATIVE
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POA1 stated to have visited the facility on 05/20/2023 and requested R1’s records, but did not receive them. POA1 sent an email to staff S1 on 06/09/2023 stating to have visited the facility on 05/20/2023 and one two other later visits and had not been given R1’s records.

The Department received a copy of the letter POA1 sent to the facility requesting R1’s records on 06/21/2023. POA1 provided the Department a copy of a screenshot of a text message from facility (ADM1) dated 06/26/2023 stating that ADM1 received POA1’s letter.

The Department obtained a photograph of the mail package label addressed to POA1 from the facility address. The mail package label states the package was sent via Priority Mail on 07/17/2023 and arrived on 07/19/2023. During interview on 07/20/2023, POA1 stated to have received R1’s records via mail on 07/20/2023.

Regarding the allegation of Staff did not follow resident's care plan, POA1 reported that facility wasn't able to get R1 ready for a doctor’s appointment and no one had been there and R1 was still in a robe and no one had taken care of R1.

The Department obtained a copy of R1’s Residency Agreement. The Basic Services section of the Residency Agreement states, “A. BASIC SERVICES. “In order to provide you with care, supervision and assistance with instrumental activities of daily living in order to meet your needs, we will provide you with the following Basic Services…Transportation – We will make available scheduled transportation services as set forth in the Addendum to the Residency Agreement…Assistance with Access to Outside Services – Community will assist you with arranging needed appointments with professionals offering medical, dental, and other health care services.”

R1‘s Personal Service Plan states R1 has a preferred AM wake and care times of between 7:30 AM and 8:30 AM and R1 needs assistance with sicks and leg wraps, with AM/PM dressing and undressing, and with back brace.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20230711095753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA
FACILITY NAME: BROOKDALE SCOTTS VALLEY
FACILITY NUMBER: 445294156
VISIT DATE: 08/16/2024
NARRATIVE
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The Department obtained a copy of an email sent from ADM1 to POA1 on 05/13/2023. In the email, ADM states, “There was a hiccup one day that caregiver did not get R1 ready in time for R1’s appointment.”

Regarding the allegation of staff did not give resident sufficient notice of rate and services increases. POA1 stated that R1 was charged an extra $3300. They said they did an assessment and said with the extra assistance R1 needed with showering and getting dressed, they were going to charge $3300.

Based on records review, R1s resident agreement states that, on page 7-8, Rate Changes, "We will provide (60) days written notice of any change in the rates for Basic Services, Personal Services, Select Services, Therapeutic Services or any other fees listed in this agreement. Additionally, we may offer or require a change in the Personal Service Plan when we determine additional services are requested or required. When such a change in services occurs and alters your Personal Service Plan, the associated fees as referenced notice of change in Exhibit A and detailed in Exhibit Z, will be charged to you immediately after written notice of change in services is provided.

According to POA1, there was no written notice provided before the increase was applied.

Therefore, based on interviews and records review and information collected, the above allegations are
determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22
cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

A copy of this report and the Appeal Rights are provided.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20230711095753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BROOKDALE SCOTTS VALLEY
FACILITY NUMBER: 445294156
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2024
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Licensee to submit a plan to address the needs of residents in care. Licensee to submit to LPA by POC deadline.
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This was not met as evidenced by: Based on interviews and records review, R1 was not ready in time for a doctors appointment which poses an immediate health, safety or personal rights risk to persons in care.

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Type B
08/23/2024
Section Cited
CCR
87468.2(a)(19)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1,... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19)To have prompt access to review all of their records ... Photocopied records shall be provided within two (2) business days...
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Licensee to submit a plan to address how the facility will comply to records requests from responsible parties. Licensee to submit to LPA by POC deadline.
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This requirement was not met as evidenced by: Based on interviews and records review, The Licensee did not ensure that resident R1’s records were provided within two business days to R1’s Power of Attorney, which poses a potential 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.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20230711095753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BROOKDALE SCOTTS VALLEY
FACILITY NUMBER: 445294156
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2024
Section Cited
CCR
87507(g)(4)(B)
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87507 Admission Agreements (g) Admission agreements shall specify the following: (4) Modification conditions, including the requirement for the provision of at least 60 days prior written notice...(B)The conditions under which a licensee may increase or change rates shall be specified in the admission agreement, pursuant to Health and Safety Code sections 1569.655 and 1569.657.
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Licensee to submit a plan to address how the facility will comply to providing notices to responsible parties regarding increases in rates. Licensee to submit to LPA by POC deadline.
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This was not met as evidenced by: Based on interviews and records review, the Licensee did not provide prior written notice to R1 regarding the increase of rates for care provided which poses a potential 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.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC9099 (FAS) - (06/04)
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