<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606301
Report Date: 10/13/2026
Date Signed: 10/13/2026 03:29:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2026 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20261007114437
FACILITY NAME:BROOKDALE MONROVIAFACILITY NUMBER:
197606301
ADMINISTRATOR:BALBIN, RALPHFACILITY TYPE:
740
ADDRESS:201 E FOOTHILL BLVDTELEPHONE:
(626) 301-0204
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:75CENSUS: 63DATE:
10/13/2026
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Mia Nakamatzu - Executive DirectorTIME COMPLETED:
03:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not dispense residents' medications as prescribed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint regarding the above-mentioned allegation. LPA met with Mia Nakamatzu, Executive Director and Kathryn Sandoval, Business Office Manager and explained the reason for the visit.

The investigation consisted of the following: LPA conducted a tour of the facility, obtained copies of the Staff and Resident rosters, Facility’s medication policy, Electronic Medication Administration Record (EMAR) sheets for (3) random residents, Resident #1 (R1) – Resident #3 (R3), (September-October 2026), Medication physician orders, Conducted audit of medications, Staff #5 (S5) – Staff #6 (S6) personnel files and medication training. LPA also interviewed Staff #1 (S1) – Staff #4 (S4), Staff #5 (S5) telephonically and Resident #1 (R1) – Resident #6 (R6). ******CONTINUED ON LIC9099-C*****
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2026
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 28-AS-20261007114437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BROOKDALE MONROVIA
FACILITY NUMBER: 197606301
VISIT DATE: 10/13/2026
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
The investigation revealed the following:

Allegation: Staff did not dispense residents' medications as prescribed. It is alleged that (2) staff members consistently dispense residents’ medications late, but they were unable to provide exact dates and unsure why their medications have been dispensed late. During the investigation, a total of (5) staff were interviewed, to which they confirmed that they had received a report regarding the same allegation. Staff stated that Monrovia Police came to investigate the allegation on Wed., 10/07/2026, and left without providing additional details. S1 stated that they have been shadowing the med techs lately to ensure that the residents medications are dispensed as prescribed. Staff interviewed confirmed that the (2) staff members (S5-S6) identified are no longer employed at the facility. S5 admitted that when they first started working by themselves on the floor, they made errors like dispensing medications to some residents late or passing medications at the wrong time or schedule. (6) of (6) residents interviewed corroborated the allegation, stating that S5-S6 regularly administered their medications late or given at the wrong schedule. While the residents could not provide the exact dates or times for these occurrences, and were unsure of the reasons behind the delays, their statements of lateness were consistent and credible. Documents reviewed including (3) random residents’ electronic medication administration record/EMAR (September 1-30, 2026), indicated that medications were recorded as given outside the approved time windows, (2 hour window, one hour before or one hour after). LPA also observed late entries on the EMAR.

Based on staff interviews, resident interviews and reviewed documentation, combined with the administrative actions resulting in the termination and resignation of S4-S5, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to the Mia Nakamatzu, Executive Director along with the Appeal Rights.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20261007114437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE MONROVIA
FACILITY NUMBER: 197606301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2026
Section Cited
CCR
87465(c)(2)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care...(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to conduct an in service training regarding safe medication administration practices and submit the in service training log to CCLD/LPA by POC due date.
8
9
10
11
12
13
14
Based on observation, interviews, records review, the Administrator did not comply with the section cited above in which Resident #1-Resident #3 medications (September 2026-October 2026) were not dispensed on time/schedule as prescribed by their physicians which poses an immediate health, safety or personal rights risk to residents in care
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3