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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 05/23/2025
Date Signed: 05/23/2025 12:32:49 PM

Unsubstantiated


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
12/05/2024 and conducted by Evaluator Marcella Tarin
COMPLAINT CONTROL NUMBER: 26-AS-20241205143226
FACILITY NAME:BROOKDALE SCOTTS VALLEYFACILITY NUMBER:
445294156
ADMINISTRATOR:KUMAR, BEENAFACILITY TYPE:
740
ADDRESS:100 LOCKEWOOD LNTELEPHONE:
(831) 438-7533
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:220CENSUS: 164DATE:
05/23/2025
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Executive Director Alex BaiasuTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff are not answering residents' call button in a timely manner
Staff yelled at resident
Resident is not being accorded dignity in personal relationship with staff at facility
Staff are not following doctor's orders for prescription medication
Facility is not following admission agreement to deliver food to resident
INVESTIGATION FINDINGS:
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On 12/5/2024 the Department received a complaint alleging that facility staff are not answering resident’s call button in a timely manner. It has been alleged facility staff took 35 minutes to respond to a call in July 2024.
On 12/11/2024 the Department conducted an unannounced initial investigation.

On 12/11/2024, 4/4/2025, 4/24/2025 and 5/14/2025, LPAs interviewed 7 staff (S1-S7) and 11 residents (R1-R11).

LPAs tested random call buttons at the facility on the following dates 4/4/2025, 4/24/2025 and 5/14/2025. LPAs tested 5 resident call buttons.

Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
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 3
Control Number 26-AS-20241205143226
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: 05/23/2025
NARRATIVE
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Based on random testing, 4 out of 5 residents call buttons were responded by staff in under 15 minutes. 1 out of 5 residents call buttons were responded by staff in 41 minutes.

Staff yelled at resident

Based on interviews, 5 out of 7 (S1-S7) staff stated staff did not yell at residents. 2 out of 7 staff stated he/she observed a staff yell at a resident. However, S3 and S5 staff did not provide information as to when the incident happened.

Based on interviews, 10 out of 11 residents (R1-R11) stated that staff does not yell at residents. 1 out of 11 residents stated staff yelled at him/her.

Resident is not being accorded dignity in personal relationships with staff at facility.

Based on interviews, 5 out of 7 (S1-S7) staff stated staff did not yell at residents. 2 out of 7 staff stated he/she observed a staff yell at a resident. However, S3 and S5 staff did not provide information as to when the incident occurred.

Based on interviews, 10 out of 11 residents (R1-R11) stated that staff does not yell at residents. 1 out of 11 residents stated staff yelled at him/her.

Staff are not following doctor’s orders for prescription medication

Based on interviews, 6 out 7 (S1-S7) staff stated staff are following doctor's orders for prescription medication. 1 out of 7 staff stated staff are not following doctor's orders for prescription medication. However, S3 did not provide information as to when the incident occurred.

Based on interviews, 11 out of 11 (R1-R11) residents stated staff are following doctor’s orders for prescription medication,

Page 2 of 3 
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20241205143226
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: 05/23/2025
NARRATIVE
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LPA reviewed the facility Medication Administration Record (MAR) for 5 residents. LPA observed medications are being administered per doctor’s orders for all 5 residents.

Facility is not following admission agreement to deliver food to resident

Based on interviews, 5 out of 7 staff (S1-S7) stated meals are being delivered to residents. 1 out of 7 staff stated he/she works the overnight shift, and meals are not served during this time. 1 out of 7 state stated meals are not being delivered to residents but did not provide information as to when the incident occurred.

Based on interviews, 5 out of 11 (R1-R11)residents stated he/she does not pay for meal delivery service. 5 out of 11 residents stated he/she pays for meal delivery services and receives his/her meals. 1 out of 11 residents stated he/she pays for meal delivery services and does not receive his/her meals. R1 stated that a day in December of 2024, his/her meal was not delivered. R1 did not provide additional information for other days meals were not delivered.

Based on interviews, document reviews and observations, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the above allegations are unsubstantiated.

No deficiencies were cited during today’s visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director (ED) Alex Baiasu and a copy of the report was provided.



SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3