445294156-6-4-2025-26-AS-MPAA-DHGV3L-20250609160454

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 06/04/2025
Date Signed: 06/04/2025 02:16:51 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
01/24/2025 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20250124092401

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: 171	DATE:	06/04/2025
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Staff Christine Monelaro		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not ensure feeding assistance was provided to resident in care
Staff allowed resident to be left in soiled clothing for extended periods of time
Staff did not reposition resident

INVESTIGATION FINDINGS:

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On 1/24/2025 the Department received a complaint alleging the above allegations. On 1/31/2025 the Department conducted an unannounced initial investigation, interviewed staff and requested copies of resident’s records to be sent to CCLD by 2/03/2025.

On 1/31/2025 - LPA Marrufo interviewed staff (S1 to S4) 4 Out of 4 staff stated residents in palliative care are checked, repositioned and changed every two hours. 4 Out of 4 staff stated that residents in palliative care are assisted with feeding when resident requests for assistance.

On 2/3/2025 - LPA Marrufo interviewed 2 witnesses and attempted to interview 1 (W1, W2, W3). W1 stated he/she did not have information about a staff member regarding feeding assistance to a resident. W1 stated they have no safety issue report or concern with R1s care.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250124092401

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: 06/04/2025

NARRATIVE

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W1 stated that W3 is not part of a care team and screamed at the staff who just checked on R1. W1 stated that W3 was angrily screaming at staff who just cared for R1 and stated that R1 was not being cared for properly. W2 cannot be contacted. W3 stated that he/she did not see the compromised skin of R1 and does not know R1s care plan. W3 stated that he/she had a feeling that nothing was done, no photos were taken. W3 stated that a Home Health Care comes to the facility to care for R1 three times a week. W3 stated family and himself/herself visited R1 and stated R1s hair was washed and bed was ‘spic and span’.

On 5/23/2025 LPA Tarin interviewed W4. W4 stated he/she provided care for R1, assisted with feeding when R1 requests for assistance.

On 4/4/2025, 4/24/2025 and 5/14/2025, LPAs interviewed 11 staff (S1-S11) and 10 residents (R1-R10).
Based on interviews, 7 out of 11 staff (S1-S11) stated staff provides feeding assistance to residents. 4 out of 11 staff stated they work the nocturnal shift, and meals are not provided during this time.

Based on interviews 10 out of 10 (R1-R10) residents stated they do not need assistance from staff with feeding.

Staff allowed resident to be left in soiled clothing for extended periods of time

Based on interviews, 7 out of 11 staff (S1-S11) stated they did not observe a resident left in soiled clothing for extended periods of times. 3 out of 11 staff stated they observed a resident left in soiled clothing. 1 out of 11 staff did not provide any information.

Based on interviews, 10 out of 10 residents (R1-R10) stated they have not observed a resident left in soiled clothing for extended period of time.

On 5/23/2025 LPA Tarin interviewed W4. W4 stated he/she did not observe R1 in soiled clothing for extended period of time.

Staff did not reposition resident

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SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250124092401

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: 06/04/2025

NARRATIVE

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Based on interviews, 10 out of 11 staff (S1-S11) stated they reposition residents based on their care plan. 1 Out of 11 staff did not provide any information.

Based on interviews, 10 out of 10 residents (R1-R10) stated he/she does not need repositioning.

On 5/23/2025, LPA Tarin interviewed W4. W4 stated he/she repositioned R1. W4 stated there were occasions when R1 did not allow him/her to be repositioned. W4 could not provide exact dates when R1 refused to be repositioned.

Based on document review of resident care plans, 1 out of 4 residents were under hospice care. 1 out of 4 residents were diagnosed with a terminal illness and major neurocognitive disorder. 3 out of 4 residents do not require feeding assistance based on the care plan. 1 out of 3 residents care plan stated that residents in hospice care are repositioned, checked and cleaned every 2 hours.

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 via phone and authorized S1 to sign on his behalf. A copy of the report was provided.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

LIC9099 (FAS) - (06/04)

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