445294156-12-21-2024-26-AS-KHOS-DCJLMA-20250102075224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 12/21/2024
Date Signed: 12/21/2024 02:24:23 PM

Substantiated

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
08/23/2023 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230823123127

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: 139	DATE:	12/21/2024
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Alex Baiasu		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not have adequate record keeping for a resident

INVESTIGATION FINDINGS:

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

The department has determined the following as it relates to the aforementioned allegation. The investigation consisted of interviews with facility staff and records review of facility records.

The reporting party alleged that the facility did not keep adequate records for Resident 1 (R1), which led to the R1 to fall behind on monthly payments and eventually evicted from the facility.
According to Staff 1 (S1) , R1 had a personal service rate that increased when R1 needed additional services. S1 explained that a nurse conducts an assessment with the resident and input information into their system, which generates the personalized plan and cost. According to S1, there is always a conversation with the resident and/or resident's responsible party. If a resident does not get to do the signing, a discussion will be done. S1 stated the facility was very transparent with R1 regarding services.

Substantiated

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: 12/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024

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 7

Control Number 26-AS-20230823123127

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: 12/21/2024

NARRATIVE

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Continued from LIC 9099

According to Staff 2 (S2), R1's personalized service plan does not have a signature but they had a discussion with R1 verbally. For R1, the facility did not have her sign the updated plan(s). S2 was unsure if the resident refusal was documented. S2 reported that R1 did not want to sign it. R1 was considered responsible for self and therefore, no other person would be able to sign on behalf of R1. S2 reported that when S2 started in 2022, R1 had an outstanding balance with the facility. S2 reported that the facility did not have a checklist of services that are provided every day and instead have shift notes from employees. S2 stated the facility was not documenting refusal of services on progress notes.

According to Staff 3 (S3), the facility provides different discounts to residents based on executive directors discretion and if a resident qualifies. If a resident qualifies for a discount rate or credit to their monthly bill, it be documented on their invoice. S3 reported that if a resident has a "Personal Solutions" charge on their monthly invoice, it is due to a resident had a delivery of supplies such as wipes, briefs, etc.

On 09/01/2023, the facility provided documents to Community Care Licensing. Documents included R1's invoices from 2013-2024, R1's Personal Service Plan dated 04/05/2023, Personal Service Plan dated 02/09/2023, Personal Service Plan dated 08/03/2022, R1's 30 Day Eviction Notice dated 05/2023, R1's progress notes dated 09/10/2022 - 11/23/2022, R1's Admission Agreement dated 12/2012, Rental Increase Notification 10/25/2013, and R1's Addendum to Residency Agreement dated 01/02/2013. During LPA Valerio's review of R1's documents, LPA Valerio observed multiple inconsistencies with invoice charges, invoice credits, and documentation/proof of R1 being properly charged for services being received.

LPA Valerio observed R1 to have an yearly increase for the Basic Service Rate every year from 2012 until 2024. LPA observed a signed document by the resident and facility for the increase in the Basic Service Rate for 2012, 2013, and 2014. From 2015 until 2024, there was no documentation provided to show the facility and the resident had a discussion or was made aware of the yearly increase.

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: 12/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 26-AS-20230823123127

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: 12/21/2024

NARRATIVE

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LPA Valerio observed an invoice dated 01/16/2023. The invoice had multiple Personal Service Rate (PSR) Charges for earlier months, 09/02/2022 - 02/282023. For 09/22 the PSR was charged as $1,930.24 on the 01/16/2024 invoice. Previously, R1's invoice dated 09/02/2022 was initially charged $193.00 for the PSR. For 10/2022 until 02/28/2023, the PSR was charge for $2,030.00. LPA Valerio observed invoices for 09/2022 to 02/2023. LPA observed the PSR was incorrectly charged to the resident during those months. According to R1's Personal Plan dated 04/04/2023, the net PSR totaled to $193.00. LPA Valerio did not observe a Personal Service Plan that stated the net PSR totaled to $1, 930.24. However, LPA Valerio observed a Personal Service Plan dated 02/09/2023 that stated the net PSR totaled to $2,223.00. LPA Valerio observed another Personal Service Plan dated 08/03/2022 that stated the Net PSR totaled to $2,223.00. These documents did not have signatures from a facility representative, R1, or any responsible party for R1.

LPA Valerio observed R1's invoices to have a charge for Personal Solutions; however, the facility did not provide a signed document showing the resident received additional services or requested the additional services.

Based on records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 26-AS-20230823123127

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/20/2025 Section Cited CCR 87506(a)	1 2 3 4 5 6 7	87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility… This requirement was not met as evidenced by: Based on staff interviews and records review, the licensee did not ensure staff properly	1 2 3 4 5 6 7	Licensee stated the Administator will send current procedure for maintaining rental increase, service increase rates, etc. LPA Valerio to receive documents by POC due date.
	8 9 10 11 12 13 14	documented R1's monthly service charges, increase in BSR, increase in PSR, additional service charges, and discussions with R1 regarding said charges. This poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 7

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
08/23/2023 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230823123127

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: 139	DATE:	12/21/2024
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Alex Baiasu		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff unlawfully evicted a resident
Staff over charged a resident for services not received

INVESTIGATION FINDINGS:

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

The department has determined the following as it relates to the aforementioned allegation. The investigation consisted of records review of facility records, interviews with facility staff, and a request of records from law enforcement officials.

On 05/05/2023, R1 was served an eviction notice due to "failed to pay sums due and owing for your residence and care at" Brookdale Scotts Valley. According to an interview with S2, the facility did not evict the resident and instead discharged the resident. S2 stated the difference between discharge and eviction is that an eviction has 3 days.

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: 12/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024

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

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 26-AS-20230823123127

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: 12/21/2024

NARRATIVE

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Continued from LIC 9099 - A

LPA Valerio provided Technical Assistance to current Executive Director Alex regarding the situation and informed current ED that R1's scenario would not be considered a discharge and still considered an eviction. If a resident were to be given a 3-Day Notice Eviction, Community Care Licensing would need to approve the eviction prior to it being issued to the resident. Reference: Title 22, Section 87224 and H&S 1569.682(a)(2)(A) through (F)

LPA Valerio reviewed R1's invoices from 2013 until 2024. LPA observed R1's less payments started in June of 2019 when R1 missed a payment. R1 made two payments for July of 2019; however, the amount was short $1,620. In addition to inconsistencies with the facility's account management of R1's services, the trend of paying below the total amount due continued until 2024. Based on the review of R1's invoices, it is unclear whether the less payments were due to the resident unable to make payments or the inconsistent service charges from the facility.

According to the eviction notice dated 05/05/2023, the facility based their eviction off failure to pay sums due for months 09/01/2022 until 04/01/2023.

Based on records review, R1 was in rehab for three (3) months and charged for monthly services. According to S2, Their admission agreement states that even if a resident is in rehab they continue payments, and therefore, the charges were warranted. However, the facility worked with R1 and credited the amount for the time R1 was in rehab. R1 was also admitted back to the facility after being in rehab.

According to R1's sign admission agreement, the following is stated: Fees during Absence: "If you are absent from the Community for any reason, such as, for a hospitalization, vacation, temporary nursing home care or rehabilitation, the Residency Agreement will remain effective and you will be charged the full Monthly Service Rate. There will be no reduction in the Meal Service Program until resident is absent from the Facility for thirty (30) continuous days. If you provide written notice of your intent to terminate the Agreement pursuant to Section IV, termination will be effective and charges will cease the later of the end of any applicable notice period or the removal of all of your personal belongings."

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: 12/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 26-AS-20230823123127

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: 12/21/2024

NARRATIVE

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LPA Dolores attempted to obtained records regarding R1's case with law enforcement. LPA Dolores attempted to obtain records two times. Due to the case being open, the documentation could not be released; therefore, LPA Dolores was unable to obtain documentation.

Due to the above noted information, although the allegation 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.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024

LIC9099 (FAS) - (06/04)

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