445294156-10-13-2024-26-AS-KHOS-DB6QTH-20241119112708

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 10/13/2024
Date Signed: 10/13/2024 12:16:07 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
07/05/2022 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20220705084955

FACILITY NAME:	BROOKDALE SCOTTS VALLEY		FACILITY NUMBER:	445294156
ADMINISTRATOR:	KAMDAR, DIMPLE		FACILITY TYPE:	740
ADDRESS:	100 LOCKEWOOD LN		TELEPHONE:	(831) 438-7533
CITY:	SCOTTS VALLEY	STATE: CA	ZIP CODE:	95066
CAPACITY:	220	CENSUS: 137	DATE:	10/13/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Alex Baiasu		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Resident's room has pests.
Resident was threatened by other residents while in care.
Resident was threatened by staff while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint investigation findings. LPA Valerio met with Executive Director Alex Baiasu, and explained the purpose of the visit.

The Department has determined the following as it relates the above mentioned allegations.

Resident's room has pest

The Reporting Party (RP) alleged that there were reports of ants on a resident's bed in June of 2022. Due to short staffing, the work orders for the ants were not addressed.

Continues on LIC 9099 - C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2024

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 4

Control Number 26-AS-20220705084955

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: 10/13/2024

NARRATIVE

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Continues from LIC 9099...

Based on facility documentation, the facility contracted with pest control services, Ecolab Pest. LPA observed Ecolab Pest serviced the facility on 05/11/22, 06/08/22, and 07/25/22. All services noted, "No ant activity…No cockroach activity was noted during the inspection and/or service." and "Preformed interior rodent service, checked and reset all traps."

Based on staff interviews, the facility has utilized Eco Lab Pest Services for years.

On 10/19/2023, the facility provided Community Care Licensing (CCL) a copy of a work order for a resident room. There were 4 pages of work order entries. Each work order was put in by staff for multiple tasks including: brake of wheel chair not working, clean carpet, blinds, roaches in kitchen, phone not working, door battery replacement, etc. LPA Valerio observed the dates were not displayed for each work orders but the work order ranged from 2020 until 2023. The work orders for the roaches did not indicate the date; however, it was noted that the work order was assigned to a specific maintenance person.

An interview was conducted on 08/02/2024 with Resident 1 (R1). R1 has lived in the community since 2021. R1 reported that there no pest issue. There were ants on R1's bed and these little black bugs mites. R1 believed they were beadles and the facility got rid of them. The facility got a complaint from staff that they saw these bugs in the dining room area. Afterwards, the dining shut down from fumigation. The interview conducted with R1 did not indicate the year of the occurrences.

According to an interview with Resident 2 (R2). R2 has not observed any ant on the bed. R2 has lived in the community for seven (7) years.

Resident was threatened by other residents while in care.

The RP reported that the RP observed Resident 4 (R4) getting yelled at by other residents and received threats from the residents. The residents did not appreciate that R4 was discussing religious information in the dining room.

Continues on LIC 9099 - C, Page 3...

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20220705084955

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: 10/13/2024

NARRATIVE

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Continued from LIC 9099 - C, page 2

CCL attempted to interview the RP on 07/05/22, 07/12/22, 08/02/2024, and 10/12/2024. All attempted were unsuccessful.

LPA Valerio learned that R1 passed away in 2022. Therefore, an interview with R1 concluded to be unsuccessful.

An interview was conducted with Resident 2 (R2) on 08/02/2024. R2 was good friends with R1. R2 indicated R1 was not aware of any residents yelling or threatening R1. R2 did not observe R1 being yelled at or threatened by residents. R1 liked to read the bible.

An interview was conducted with Staff 1 (S1) on 08/02/2024. According to S1, R1 read R1's bible out loud which tended to irritate some individuals. S1 reported some resident would say “take [R1] out of here”. The staff would intervene to the resident nicely. S1 did not report observing any threats to R1.

An interview was conducted with Staff 2 (S2) on 08/02/2024. According to S2, R1 would read the bible in the dining room. The residents that didn’t like it would tell him to shut up and call staff to complain about it.

An interview was conducted with Staff 3 (S3) on 08/02/2024. According to S3, S3 remembers R1 reading the bible in the dining room every day. It was R1's mission in life. R1 was hard of hearing and to communicate people had to yell at him. S3 reported residents would constantly yell at R1 and say to get the hell out of here. Staff would offer another room for R1 to carry about R1's bible readings.

An interview was conducted with Staff 6 (S6) on 10/12/2024. According to S6, R1 was a wonderful and kind person. Other residents would say "Get the f out here" but it was not observed to be threats towards R1. When that would happen, staff would take R1 out of the dining room, and offer R1 another common area for R1 to be in. Some residents do not like to hear about God, especially if they are not religious. R1 would be very loud to the point where you could hear R1 from the lobby area.

Continues on LIC 9099 - C, page 4

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20220705084955

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: 10/13/2024

NARRATIVE

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Continued from LIC 9099-C, page 3

Resident was threatened by staff while in care.

According to the RP, the RP stated Executive Director (ED) Dimple Kamar threatened that R1 would be banned from the dining room in 2022 due to R1's speaking out loud about his religion. LPA Valerio learned that ED Dimple Kamar has not been the ED for some time; therefore, an interview with him is deemed unsuccessful.

According to interviews with R1 and R2, they do not recall R1 ever being banned from the dining hall. R2 reported that staff are respectful. According to interviews with S1, S2, S3, S4, and S5, R1 was never banned from the dining hall and the facility would never have implemented this plan.

Due to the above noted information, although the allegation(s) 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 with ED Alex Baiasu.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2024

LIC9099 (FAS) - (06/04)

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