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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294156
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:14:50 PM

Document Has Been Signed on 01/15/2025 02:14 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: 146DATE:
01/15/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Executive Director, Alex BaiasuTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management to conduct a Quarterly Visit and met with Executive Director (ED) Alex Baiasu. The purpose of this visit is to ensure that the facility is adhering to the facility's Action Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 8/13/2024.

During visit, LPA reviewed staff training on personal rights and proper resident approach, as part of the facility's Action Plan submitted to the Department on 8/20/2024. LPA reviewed documentation of staff training conducted on 9/6/2024 which included topics such as Resident Approach/Resident Rights, and Safe Resident Handling. LPA observed the Training Attendance Form which was signed by facility care staff on 9/6/2024. ED states random check-ins are being conducted daily with staff to ensure adherence to residents personal rights and proper approach protocols. The facility is adhering to the facility's Action Plan for staff training.

At 1:45PM LPA observed an all staff meeting being conducted by Management.

No deficiencies cited as per California Code of Regulations, Title 22. This report was reviewed with Executive Director (ED) Alex Baiasu and a signed copy of this report was provided.
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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