445294156-11-9-2024-26-AS-KHOS-DB6QTG-20241119112707

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 11/09/2024
Date Signed: 11/09/2024 03:09:41 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: 134	DATE:	11/09/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Alex Baiasu		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident was handled in a rough manner while in care.
Resident was spoken to in an inappropriate manner while in care.
Medical attention was not sought for a resident in a timely manner.

INVESTIGATION FINDINGS:

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

The following has been determined as it relates to the aforementioned allegations.

On 0705/22, the Reporting Party (RP) stated an incident occurred a week on 06/24/22 prior involving an unnamed resident and a staff member. The alleged staff member, who worked for Cebu Staffing Agency, was assisting a resident with showering and applying a cream. The staff member was very rough with the resident and caused a skin tear while applying the cream. During this time, it was reported the alleged staff member told the resident they were fat and needed to walk.

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: 11/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024

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-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: 11/09/2024

NARRATIVE

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Continued from LIC 9099

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

According to an interview with Staff 3 (S3), S3 reported working during 2022. S3 reported recalling residents
Complaining about the third party agency staff. There was internal investigation, but is unaware of the outcome. The incident described by S3 was similar to the information provided by the RP. Those who received a complaint, did not return to work.

According to an interview with Staff 5 (S5), S5 stated the facility no longer uses Cebu Staffing agency. S5 is unaware of the incident. S5 stated the Wellness Director in 2022 is no longer working for Brookdale Scotts Valley.

According to the RP, the incident was reported by the RP to the Health and Wellness Director; however, the resident's wounds were not address until 06/28/2022.

According to an interview with Resident 1 (R1), R1 recalled a caregiver was rushing to help R1 when R1 first moved into the facility in 2022. R1 reported the staff was putting cream on R1's stomach area really hard and fast, which made R1 bleed. The skin tear was about three inches. R1 was given first aid a few days later. R1 did not recall the name, but could recall the race of the individual. R1 recalls never seeing the staff after R1 told the front desk. R1 said the staff was also the person to say R1 was fat and needed to walk up and down the hallway.

According to R1's LIC 601 dated 10/22/2021, R1 was able to administrator own prescription medications, injections, glucose testing, PRN medications, and store own medications.

According to an interview with Staff 7 (S7), S7 reported R1 was not on medication management during 2022; therefore, staff nor the facility have record of the medications provided to R1.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 11/09/2024

NARRATIVE

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Continued from LIC 9099 - C, page 2

On 10/18/2024, LPA Valerio requested staff records and call button logs for June 2022. Due to the amount of time since the initial opening of the complaint, the facility needed to contact vendors for data from two years ago.

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: 11/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3