445294156-5-14-2025-26-AS-KHOS-DGTMG6-20250519093524

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 05/14/2025
Date Signed: 05/14/2025 01:20:27 PM

Unfounded

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
09/19/2024 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20240919113044

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: 163	DATE:	05/14/2025
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Executive Director Alex Baiasu.		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Staff are not allowing resident to have visitors
Staff are inappropriately isolating resident
Staff are inappropriately punishing resident
Staff are mismanaging residents medication
Unqualified staff is administering medication to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Executive Director Alex Baiasu.

On September 19, 2024, the Department received a complaint alleging Staff are not allowing resident to have visitors. It has been R1’s family member cannot visit R1.

On September 27, 2024, LPA Steve Chang and Marcella Tarin conducted an unannounced initial investigation visit.

On September 27, 2024, LPA Steve Chang and Marcella Tarin interviewed resident R1. R1 stated his/her wife/husband can come at any time.
Page 1 Out of 5.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

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 7

Control Number 26-AS-20240919113044

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: 05/14/2025

NARRATIVE

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LPA Chang and Tarin interviewed Executive Director (ED). ED stated visitors can visit anytime, 24 hours a day. ED stated the only time a visitor is refused is when the resident refuses a visitor.

On April 4, 2024, LPA Monter and Tarin interviewed residents R2-R5. All residents interviewed stated; the facility allows residents to have visitors. All residents interviewed stated the facility does not ban or block visitors from visiting their family members.

On April 4-21, 2025, LPA Monter interviewed staff S4-S8. All staff interviewed stated the facility allows residents to have visitors. All staff interviewed stated the facility does not ban or block visitors from visiting their family members.

On April 24, 2025, LPA Monter interviewed residents R6-R13. All residents interviewed stated; the facility allows residents to have visitors. All residents interviewed stated the facility does not ban or block visitors from visiting their family members.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Staff are inappropriately isolating resident/Staff are inappropriately punishing resident

On September 19, 2024, the Department received a complaint alleging Staff are inappropriately isolating resident / Staff are inappropriately punishing resident. It has been alleged that facility staff are punishing resident R1 by isolating him/her.

On September 27, 2024, LPA Steve Chang and Marcella Tarin conducted an unannounced initial investigation visit.

On April 4, 2024, LPA Monter and Tarin interviewed residents R5-R8. All residents interviewed stated; they have not seen residents being punished or residents isolated by staff.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 26-AS-20240919113044

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: 05/14/2025

NARRATIVE

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On April 4-21, 2025, LPA Monter interviewed staff S4-S8. All staff interviewed stated they haven’t seen residents being punished or residents isolated by staff.

On April 24, 2025, LPA Monter interviewed residents R9-R13. All residents interviewed stated; they have not seen residents being punished or residents isolated by staff.

On May 14, 2025, LPA Monter interviewed R1. Resident R1 stated he/she was not being isolated or punished.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Staff are mismanaging residents medication

On September 19, 2024, the Department received a complaint alleging Staff are mismanaging residents medication. It has been alleged that staff are not administering residents insulin shots.

On September 27, 2024, LPA Steve Chang and Marcella Tarin conducted an unannounced initial investigation visit.

On April 4, 2024, LPA Monter and Tarin interviewed residents R5-R8. Residents R2, R3, R5 stated they have been getting their medications everyday and have not had a missed medication. Resident R4 stated he/she handles his/her own medication and doesn’t need staff assistance.

On April 4-21, 2025, LPA Monter interviewed staff S4-S8. S4 stated Staff S1 wasn’t administering medication to residents. S4 stated staff S1 is marking on the computer that he/she administered medication, but he/she is lying on the form. S5 - S8 stated residents are getting their medications and there hasn’t been a day when medication was missed. Staff S5-S8 stated they have not observed staff making up dosages on residents medications.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 7

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
09/19/2024 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20240919113044

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:	05/14/2025
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:			TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Staff are not ensuring residents are given showered

INVESTIGATION FINDINGS:

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On September 19, 2024, the Department received a complaint alleging Staff are not ensuring residents are given showered. It has been alleged residents are not getting showers.

On September 27, 2024, LPA Steve Chang and Marcella Tarin conducted an unannounced initial investigation visit.

On April 4, 2024, LPA Monter and Tarin interviewed residents R2-R5. Residents R2-R4 stated they don’t need assistance with showers. Resident R5 stated he/she gets assistance with showers and has no complaints. All residents interviewed stated they have not seen any residents who appeared unshowered or neglected in terms of their hygiene.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

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 7

Control Number 26-AS-20240919113044

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: 05/14/2025

NARRATIVE

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On April 4-21, 2025, LPA Monter interviewed staff S4-S8. S4 stated Residents are not being showered because of being short of staff. S4 stated resident R1 isn’t receiving a shower. S4 stated R1 is being showered every 2 weeks. S5 stated There are times when staff are short staff. S5 Stated when staff are busy, they can’t meet shower schedule and need to move time of shower, but the resident is showered the same day. S5 stated he/she has not seen residents who appeared unshowered or neglected in terms of their hygiene.

S6 stated he/she will sometimes find residents unshowered at the start of his/her shift, but he/she will shower the residents. Staff S7 stated the residents are being showered. S7 stated residents have 2 shower days a week minimum. S8 stated he/she has found residents not showered. S8 stated the residents are eventually showered, but the short staffing makes delays.

On April 24, 2025, LPA Monter interviewed residents R6-R10. Resident R6 stated he/she gets assistance with showers and has no complaints. R7 and R9 stated they get showered from his/her family member and does not need assistance from the facility staff. R8 stated because the facility is short staffed, the shower schedule has been inconsistent. R8 stated he/she would get his/her shower every 2 weeks. R10 stated he/she does not need assistance from facility staff to take a shower. All residents interviewed stated they have not seen any residents who appeared unshowered or neglected in terms of their hygiene.

On May 14, 2025, LPA Monter interviewed resident R1. Resident R1 stated he/she is getting his showers weekly. R1 stated he/she does refuse showers sometimes because he/she doesn't like to deal with the hassle of showering.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 26-AS-20240919113044

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: 05/14/2025

NARRATIVE

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On April 24, 2025, LPA Monter interviewed residents R9-R13. Resident R6 & R8 stated they have been getting their medications everyday and have not had a missed medication. R10, R12 & R13 stated he/she handles his/her own medication and doesn’t need staff assistance.

On May 14, 2025, LPA Monter interviewed residents R1, R2, R4 & R14. All residents interviewed stated they have been getting their medications everyday. All residents interviewed stated there hasn't been a day when medication has been missed.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Unqualified staff is administering medication to residents

On September 19, 2024, the Department received a complaint alleging Unqualified staff is administering medication to residents. It has been alleged that a staff member who is unqualified to administer shots, S1, has been administering shots.

On September 27, 2024, LPA Steve Chang and Marcella Tarin conducted an unannounced initial investigation visit.

On September 27, 2024, LPA Chang and Tarin interviewed staff S1. S1 stated he/she does not have his/her license yet, but I have nclex (State board licensing) next month to obtain license for LVN. S1 stated he/she has a permit, but it expired. S1 stated the permit means you can only practice with another nurse. S1 stated he/she cannot practice independently. S1 stated he/she was able to administer and inject insulin before his/her permit expired.

Based on a review of S1’s staff file, S1’s interim permit from the board of vocational nursing was issued on November 6, 2023 and valid until August 6, 2024. S1’s Vocational Nurse license was issued on October 22, 2024, with an expiration date of August 31, 2026.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 26-AS-20240919113044

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: 05/14/2025

NARRATIVE

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On May 14, 2025, LPA Monter interviewed residents R2, R4 & R14. All residents interviewed stated they have been getting their medications everyday. All residents interviewed stated there hasn't been a day when medication has been missed. All residents interviewed stated they do not remember who administered their medication from August 7- October 21, 2024.

LPA Manuel Monter reviewed resident insulin administration log for the months of August and October 2024.

LPA reviewed 3 resident insulin, E-Mar. Based on a review, Staff S1 didn't administer insulin medications based on what is stated on the E-mar, from the dates, August 7- October 21, 2024.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Page 5 Out of 5. END OF REPORT.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

Page: 7 of 7