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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294156
Report Date: 08/09/2022
Date Signed: 08/09/2022 03:13:52 PM


Document Has Been Signed on 08/09/2022 03:13 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:BROOKDALE SCOTTS VALLEYFACILITY NUMBER:
445294156
ADMINISTRATOR:KAMDAR, DIMPLEFACILITY TYPE:
740
ADDRESS:100 LOCKEWOOD LNTELEPHONE:
(831) 438-7533
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:220CENSUS: 135DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Dimple KamdarTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced annual inspection today and met with Interim Administrator (Admin) Dimple Kamdar.

LPA entered the facility through designated central point of entry and was screened by staff. LPA observed staff screen visitors and residents. COVID-19 postings were observed in the hallways, but lacking in common areas like the bingo room, library, and exercise room. Staff, residents in common areas, and visitors were observed to be wearing face coverings. Hand sanitizers, soap, and paper supplies were observed to be available. At least 30 days' supply of personal protective equipment (PPE) were available in the premises.

LPA toured the facility including 2 dining rooms, maintenance room, library, activities office, kitchen, theater, bingo room, exercise room, beauty salon, 2 facility courtyards, and 10 resident bedrooms. Temperature observed between 71*F and 77*F. Facility water temperature measured between 113.7*F and 119.6*F. Facility was observed to have at least 2 days worth of perishable and one week's supply of nonperishable food. All rooms were observed to be clean and well maintained. All emergency exits observed to be free from obstruction. No prohibited items noted in any resident rooms.

The facility has reached approximately a 90% and 100% COVID-19 vaccination rate for residents and staff respectively. The facility's weekly activity schedule was reviewed and included exercises, craft classes, games, and musical activities. The facility's infectious control plan has been submitted and is currently under review by the department..

No deficiencies were cited. Exit interview conducted with Administrator and a copy of this report was provided during visit.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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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