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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294156
Report Date: 04/09/2022
Date Signed: 08/01/2022 04:49:53 PM


Document Has Been Signed on 08/01/2022 04:49 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
, 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: 130DATE:
04/09/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Christine MontelaroTIME COMPLETED:
12:47 PM
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Licensing Program Analyst Ryker Heberle (LPA) and Licensing Program Manager Sarah Yip (LPM) conducted a tour of the facility in response to a recent COVID-19 outbreak among residents. LPA and LPM met with the facility's Business Office Manager Christine Montelaro (BOM).

LPA and LPM toured the facility with BOD including facility entrance, dining hall, kitchen, 4 public restrooms, PPE storage closet, hallways to resident rooms, screening room, bingo room, courtyard, and outdoor visitation areas. LPA and LPM observed numerous factors indicating that the facility was not currently following mitigation plan, including residents eating in dining hall without social distancing, PPE carts outside of isolation rooms lacking necessary PPE items, no social distancing, masking, or other precautionary signage, and no check in/screening table in the entrance area, no separate break area for staff members assisting COVID positive residents, and staff designated as assisting positive residents also assisting negative residents.

LPA and LPM made the following recommendations for the facility to implement effective immediately:
    1) Post COVID precaution signs on the door of designated central entry point
    2) Ensure that precautionary signs are posted in all common areas/front doors
    3) Reestablish sign-in table at the front area for entry screening
    4) Handwashing signs to be posted above all sinks in bathrooms, kitchens, break rooms, etc.
    5) Restock paper towels in all bathrooms
    6) Use one of the currently closed common rooms as a break room for staff members that work with COVID positive residents
    7) Close dining hall for the duration of the outbreak

Continued on 809-C
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 04/09/2022
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LPA and LPM made the following recommendations for the facility to implement:
    8) Make all activities outdoor for the duration of the outbreak
    9) Post signage on doors of isolation rooms indicating red zone status
    10) Post signage on doors of isolation rooms indicating the correct order of donning and doffing PPE
    11) Make sure PPE carts are fully stocked at all times
    12) Place trash cans inside isolation rooms as well outside isolation rooms for discarding of used PPE
    13) Ensure that all laundry of positive residents is kept separate from negative resident laundry
    14) Ensure positive resident laundry is sealed during transit to laundry room
    15) Update line list to indicate hospice status of all COVID positive residents
    16) Update infection control plan / mitigation plan and determine who is the infection control lead
No deficiencies cited during this visit. LPA provided BOD with all necessary signage to post throughout the facility. This report was reviewed with facility Business Office Director Christine Montelaro and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2