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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 11/03/2023
Date Signed: 11/03/2023 02:15:32 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
10/25/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20231025155125
FACILITY NAME:BROOKDALE SCOTTS VALLEYFACILITY NUMBER:
445294156
ADMINISTRATOR:KUMAR, BEENAFACILITY TYPE:
740
ADDRESS:100 LOCKEWOOD LNTELEPHONE:
(831) 438-7533
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:220CENSUS: 125DATE:
11/03/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Alex BaiasuTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff did not ensure faciltiy was free of pests
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Associate Executive Director, Alex Baiasu.

On 10/25/2023, the Department received a complaint alleging staff did not ensure facility was free of pests. On 11/03/2023, the initial complaint investigation was conducted. Documents were obtained for allegation to include the facility’s pest control services statements and pest control customer service reports from July 2023 – Present.

On 11/03/2023, 2 staff members were interviewed. Based on interviews, the facility has a contract with a pest control company. The facility has visits from the pest control who services the facility frequently and on an as needed basis. Staff stated if that there are any suspicions of pests in the community that is voiced by the staff or residents, they contact the pest control company for service. SEE LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
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 3
Control Number 26-AS-20231025155125
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: 11/03/2023
NARRATIVE
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Based on record review, the pest control company provided service at the facility on 07/05/23, 07/12/23, 07/13/23, 07/25/23, 08/15/23, 08/24/23, 09/14/23, and 09/20/23. Each service contains a comment on items the pest control company has completed and if there were any findings of pests. Based on the dates of service, there were no indications of physical findings of pests, however, findings of mice droppings were observed in 3 resident apartments on 08/15/2023. The droppings were cleaned from the resident’s apartments. The pest control applied measures to terminate the pests.

The Department has investigated the above allegation. Based on interview, record review, and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did nor occur. This report was reviewed with Executive Director, Alex Baiasu and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3