445294156-10-19-2023-26-AS-RMAO-D8UNY5-20240906105209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 10/19/2023
Date Signed: 10/19/2023 05:03:40 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/17/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20230817122122

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: 120	DATE:	10/19/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Dimpler Kamdar		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff admitted resident with prohibited health conditions.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Steve Chang and Maria Partoza conducted an unannounced investigation visit to deliver the investigation finding and met with Operation Specialist/Interim Executive Director (OS/IED) Dimple Kamdar.

On 08/17/2023, the Department received a complaint with an allegation that staff admitted resident with prohibited health conditions.

On 08/21/2023, an initial investigation visit was conducted. LPAs obtained resident physician report, Assessment report, Progressive Notes, discharged documents, and roster of clients. LPAs interviewed Executive Director (ED), 1 staff (S1), and two residents (R1, R2).

Continue on LIC9099-C. Page 1 of 2.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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 2

Control Number 26-AS-20230817122122

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BROOKDALE SCOTTS VALLEY	FACILITY NUMBER: 445294156
	VISIT DATE: 10/19/2023

NARRATIVE

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Staff admitted resident with prohibited health conditions:
On 8/21/2023, LPAs interviewed Executive Director (ED) regarding allegation that the facility readmitted a resident with prohibited health condition. Per ED the facility's Health and Wellness Director (HWD) evaluated and assess the resident (R1) before readmitting to the facility and was cleared to return to their facility.

LPAs interviewed and observed R1. LPAs observed that R1 was able to do their activities of daily living (ADL) with some assistance. He/she is able to eat, drink, groom himself/herself.

LPAs interviewed day staff (S1) who reviewed R1s assessment and intake evaluation. S1 provided care to R1 and stated that R1 is able to do his/her ADLs but needs some assistance getting in and out of the bed and showering.

On 8/25/2023, LPA interviewed Home Health Care Provider. Provider stated he/she took care of R1 since R1 moved back to the facility and stated that R1s condition is improving.

Based on the interviews, observations and reviews of documents, the allegation based on Title 22 under the prohibited health condition is UNFOUNDED and preponderance of evidence is not present. Meaning that the allegations were false or could not have happened and/or are without reasonable basis.

On 10/19/2023 - during a follow up visit, LPAs was informed by HWD, that R1 moved to a different facility on 10/3/2023. HWD stated R1s condition changed that required a higher level of care on 10/3/2023. Prior to R1s move, R1's condition has improved from the initial visit in August.

Exit interview was conducted with Operational Specialist/Interim Executive Director (OS/IED). This report was reviewed with OS and a copy of this report was provided to OS/IED.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2