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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294156
Report Date: 04/15/2022
Date Signed: 04/15/2022 06:01:08 PM


Document Has Been Signed on 04/15/2022 06:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:BROOKDALE SCOTTS VALLEYFACILITY NUMBER:
445294156
ADMINISTRATOR:EDWARDS, ANTONETTEFACILITY TYPE:
740
ADDRESS:100 LOCKEWOOD LNTELEPHONE:
(831) 438-7533
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:220CENSUS: 141DATE:
04/15/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Christine MontelaroTIME COMPLETED:
06:02 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced site inspection on 04/15/2022 to ensure that the facility had implemented all recommend COVID-19 precautions from previous Department visits, as well as HAI inspection conducted on 04/13/22. LPA met with facility Business Operations Managers Christine Montelaro and Patricia Olvera (BOMs). Interim Executive Director Robert Alverado attended telephonically.

LPA observed for implementation of following recommendations:
    1. N95 respirators should be designated for healthcare and fit-tested for all Healthcare Personnel - LPA confirmed with Administrator Robert that N95s of various sizes have been ordered and staff have been informed to visit clinic for fit testing.
    2. The CDC guidance states that HCP working in facilities located in counties with substantial or high transmission should also use Eye protection during all patient care encounters. - LPA did not observe staff providing patient care, but obserbed adequate supply of eye protection
    3. Continued cooperation from the residents to wear masks while in the hallways and public areas of the facility. - All residents observed to be wearing face masks in common areas
    4. To decrease risk of transmission, continue to encourage social distancing in break rooms by separating tables and chairs and providing signage indicating that staff must eat at separate tables. - Break rooms observed to be properly set up to accommodate social distancing
    5. The disinfectant wipe used by the facility is not on the EPA List N for disinfectants effective against COVID-19. - LPA observed disinfectants wipes and confirmed ordering of additional supplies
    6. There was not signage delineating transmission-based precautions. - LPA observed signage posted in all common areas, transition signage not observed in 300 hallway. PPE signage observed in all necessary locations

    Continued on 809-C
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: BROOKDALE SCOTTS VALLEY
FACILITY NUMBER: 445294156
VISIT DATE: 04/15/2022
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HAI recommendations continues below:
    7. Appropriate donning and doffing of PPE. - LPA observed facility staff properly don and doff PPE and confirmed attendance sheet of offered training from 04/15 and 04/13
    8. To avoid staff cross contaminating their personal environment, consider a trashcan and Alcohol Based Hand Rub on the outside of the facility for doffing PPE upon exiting the building as well as signage instructing staff on use. - Trash can and hand sanitizer station observed outside facility
    9. Track the percentage of residents that are up to date with all recommended COVID-19 vaccinations. - LPA observed facility vaccination statistics, Admin indicated that booster statistics are currently outdated, as some residents were boosted independently with their families, facility is currently working with families to compile that information
    10. Separate chairs and sofas in the facility used by residents for gathering. - Communal area chairs and sofas observed to be adequately social distanced
    11. When using outdoor spaces for activities, socially distance and enforce the use of masks among the residents. LPA did not observe any residents in outdoor activity areas, but observed grounds to be adequately set up for social distancing
    12. Consider placing additional Alcohol Based Hand Rub throughout the inside hallways of the facility. - LPA observed stocked hand sanitizer contains throughout facility hallways. Admin indicated that the facility had ordered additional sanitizer dispensers currently en route to the facility.
During tour of the facility, LPA observed 4 community isolation rooms. 1 out of 4 isolation rooms was missing N95 masks in PPE cart located outside of room, 1 out of 4 isolation rooms was observed to have only one nonreusable face shield. Med carts were restocked with PPE while LPA was on site. 1 out of 4 isolation rooms observed to have slightly opened door. Facility Medication and Wellness Director Kim La Force stated that the room had been thoroughly cleaned/sanitized and that the resident had not been in the room since he/she was sent to the hospital. MWD closed the door and demonstrated proper donning and doffing procedure.

As of this writing, proof of facility reporting to CCLD and Department of Public Health within 24 hours of outbreak has not yet been submitted.

Deficiency cited, see 809-D this report was reviewed with Christine Monrelaro, Business Operations and Administrator Robert Alverado and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2022 06:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: BROOKDALE SCOTTS VALLEY
FACILITY NUMBER: 445294156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2022
Section Cited

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80061 - Reporting Requirements - Upon the occurrence... of the events specified... a report shall be made to the licensing agency within the agency's next working day during its normal business hours... (H) Epidemic outbreaks. This requirement was not met as evidenced by:
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Based on records review, the licensee did not comply with the section cited above by not reporting COVID positive residents and staff member to licensing within 24 hours, which posed an immediate health, safety or personal rights risk to persons in care.
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
LIC809 (FAS) - (06/04)
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