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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294156
Report Date: 12/11/2024
Date Signed: 12/11/2024 04:08:49 PM

Document Has Been Signed on 12/11/2024 04:08 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/
DIRECTOR:		KUMAR, BEENAFACILITY TYPE:
740
ADDRESS:100 LOCKEWOOD LNTELEPHONE:
(831) 438-7533
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY: 220CENSUS: 141DATE:
12/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Alex BaiasuTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analysts (LPAs) David Marrufo and Marcella Tarin conducted an unannounced Case Management visit and met with Administrator (ADM) Alex Baiasu.

The purpose of the visit was to conduct a follow-up visit for two SOC341 Suspected Adult/Elderly Abuse forms that were submitted by the facility to the Department on 09/09/2024. The first SOC341 form was for resident R1, who reported to facility staff that $300 in cash and two necklaces belonging to R1 had been stolen. The second SOC341 stated that R2 reported to staff that a necklace valued at $2000 and two earrings valued at $500 belonging to R2 had been stolen.

During visit, LPAs interviewed ADM, who stated that staff S1 had been under investigation by local law enforcement for thefts occurring outside of the facility. ADM played a voicemail left on ADMs phone by someone identifying himself/herself as local law enforcement and stated that the investigation into a staff member of ADM's facility for a theft of a house had named the staff as a suspect. The law enforcement officer stated in the voicemail that law enforcement could not prove that the staff stole items from the house. ADM stated that law enforcement had arrived to the facility at an earlier date and confiscated S1's telephone. ADM stated that S1 reported during interview with ADM that S1 had visited the facility outside of S1's working hours and had established friendships with family members of residents. ADM stated S1 told ADM that S1 spends time with family members of residents outside of the facility. ADM stated to have not submitted LIC624 Unusual Incident/Injury Reports for the reported thefts of R1 and R2's belongings.

See LIC809-C for more information.

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SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: BROOKDALE SCOTTS VALLEY
FACILITY NUMBER: 445294156
VISIT DATE: 12/11/2024
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During visit, LPAs obtained a copy of the Suspension Form issued to S1. The form is dated 10/04/2024 and is signed by R1 and ADM. The form states S1 is being placed on suspension pending an investigation into allegations of theft.

During visit, LPA Marrufo interviewed resident R1. During interview, R1 stated to have found R1's necklace in a dresser drawer, but was still missing R1's $300.

ADM stated during interview that R1 reported to ADM that R1 reported to have found the $300.

ADM stated during visit that R2 had left the facility with a family member today.

During visit, LPA Marrufo interviewed staff S2 and S3. S2 stated to have not observed or heard of any reports of any resident items being missing or stolen. S3 stated that R2 reported to S3 to have found R2's missing necklace and to have had misplaced it. S3 stated to have observed R2 wearing the necklace.

During visit, LPAs obtained copies of R1 and R2's Identification and Emergency Information Forms.

LPAs obtained copies of R1 and R2's Safeguard for Property and Valuables Forms. Both R1 and R2's Safeguard for Property Valuables forms claimed no items.

During visit, LPA observed the Theft and Loss Policy posted in the facility lobby area.

Advisory Notes were issued. See LIC9102 pages for more information.

No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with ADM Alex Baiasu and a copy of this report was provided.

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END REPORT
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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