445294156-4-24-2025-26-AS-KHOS-DGLNC4-20250512102007

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 04/24/2025
Date Signed: 04/24/2025 11:06:20 AM

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 Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20231025155125

FACILITY NAME:	BROOKDALE SCOTTS VALLEY		FACILITY NUMBER:	445294156
ADMINISTRATOR:	KUMAR, BEENA		FACILITY TYPE:	740
ADDRESS:	100 LOCKEWOOD LN		TELEPHONE:	(831) 438-7533
CITY:	SCOTTS VALLEY	STATE: CA	ZIP CODE:	95066
CAPACITY:	220	CENSUS: 159	DATE:	04/24/2025
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Administrator, Alex Baiasu		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not notify authorized represenative that the resident went to the hospital
Resident was left on floor for an extended period of time

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Administrator Alex Baiasu.

On October 25, 2023, the Department received a complaint alleging Staff did not notify authorized representative that the resident went to the hospital. It has been alleged that On August 18, 2023, R1 suffered a medical emergency and was sent the hospital. It has been alleged the facility did not notify the family of the 911 call.

On March 28, 2025, LPA Monter interviewed R1’s family member (FM). FM stated he/she doesn’t know if the facility contacted him/her the same day or within 24 hours. FM stated he/she doesn’t know if R1’s power of attorney was contacted on August 18, 2023.
Page 1 Out of 4.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

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 4

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: 04/24/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On April 4, 2024, LPA Monter interviewed R1’s Power of Attorney. (POA). POA stated he/she thinks he/she was not contacted but cannot say for sure. POA stated it was a long time ago.

On April 4, 2024, LPA Monter interviewed staff S1. Staff S1 stated he/she did recall the incident regarding R1, and he/she having to move bedrooms due to the mice issue. Staff S1 stated he/she did call the POA and informed him/her that R1 was going to the hospital on August 18, 2023. S1 stated the POA was contacted almost immediately.

Based on a review of Resident R1’s progress notes, dated August 18, 2023, R1 was transferred to a different room because his/her room had mouse issues. R1 was sitting in his/her wheelchair while maintenance was fixing his/her bed. R1 was unresponsive and started to throw up. R1 was sent out to the hospital. R1’s responsible party was notified by staff S1.

Based on a review of the facility program, "whenever a resident needs medical attention, an immediate, on the spot assessment must be made of the resident's condition...if the resident is comatose or incoherent...call the relative or person listed on the card...if the resident is conscious and has requested assistance...contact the relative or person listed on their card..."

The Department was unable to interview Resident R1, who no longer lives at the facility.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Resident was left on floor for an extended period of time

On October 25, 2023, the Department received a complaint alleging resident was left on floor for an extended period of time. It has been alleged that in July 2023, resident R1 had fallen out of bed and was out of bed for over 2 hours before assistance arrived.
Page 2 Out of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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: 04/24/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On March 28 2025, LPA Monter interviewed R1’s family member (FM). FM stated he/she doesn’t know how long R1 was laying on the floor when he/she fell on July 1, 2023. FM stated he/she only knows what R1 told him/ her.

On April 4, 2025, LPA Monter and Tarin interviewed residents R2-R5. All residents interviewed stated they have not seen residents who were left on the ground unattended for an extend period of time. Residents R2 and R3 stated the facility staff respond to pendants in a timely manner. Resident R4 stated he/she has never used the pendant or call bell system. Resident R5 stated he/she has used his/her pendant/ call bell system. R5 stated the staff does not respond timely. R5 stated especially at night, staff will respond in 45 minutes.

On April 4, 2025, LPA Monter tested the pendant pull cord system in resident bedroom 247. The facility staff responded to the activated pendant/cord system and arrive to the residents bedroom in 10 minutes and 30 seconds. LPA Monter also tested the cord system in bedroom 414. Facility staff were able to respond and arrive to the residents bedroom, in four minutes.

On April 4 2025, LPA Monter interviewed R1’s power of attorney (POA). POA stated he/she doesn’t know how long R1 was laying on the floor when he/she fell on July 1, 2023. FM stated he/she only knows what R1 told him/her.

On April 2025, LPA Monter interviewed staff S2-S5. S2 stated he/she was not working when R1 got stuck in the bed rails. S3 stated he/she does remember resident R1 but doesn’t remember when R1 got stuck. S3 stated it was a long time ago, and has a rough glimpse of that day, but doesn’t recall. Staff S4 stated he/she remembers the fall that R1 had on July 1, 2023. S4 stated R1 had his/her hand stuck. S4 stated it was one of the night shift care givers responded that night, immediately. S4 stated she doesn’t remember who it was but stated it might be either S3 or S2.

Page 3 Out of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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: 04/24/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on a review of R1’s Progress notes, dated July 1, 2023, at around 3:10 in the morning, resident called thru his/her pendant. When staff arrived, R1 was on the floor, with his/her right-hand suck on the bed side rail. Staff helped R1, and 911 was contacted for more assessment. R1’s responsible party was contacted.

The Department was unable to interview Resident R1, who no longer lives at the facility.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No deficiencies cited, an exit interview conducted with Administrator, Alex Baiasu and a copy of the report was provided.

Page 4 Out of 4. END OF REPORT.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4