197606682-8-19-2020-11-AS-JHAD-BTVUUL-20200928155342

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606682
Report Date: 08/13/2020
Date Signed: 08/19/2020 01:06:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2020 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20200731141815

FACILITY NAME:	BROOKDALE SANTA MONICA GARDENS		FACILITY NUMBER:	197606682
ADMINISTRATOR:	RALPH BALBIN		FACILITY TYPE:	740
ADDRESS:	851 2ND ST		TELEPHONE:	(310) 393-2260
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90403
CAPACITY:	128	CENSUS: 69	DATE:	08/13/2020
		UNANNOUNCED	TIME BEGAN:	01:04 PM
MET WITH:	Ralph Balbin Administrator		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Staff do not have planned activities for residents while in care

INVESTIGATION FINDINGS:

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On 08/13/2020 around 2pm Licensing Program Analyst (LPA) Jose Calderon conducted a subsequent complaint visit to render investigation findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically via face time with Ralph Balbin, the Administrator.
The Investigation consisted of the following: On 8/5/2020 around 2:00 pm LPA Calderon conducted a telephone interview via face time with the administrator Ralph Balbin, interview with Activities Director Ashley Shire and conducted a tour which consisted of a inspected all common rooms. On 08/12/2020 around 2 pm LPA interviewed residents # 1-10 regarding the allegation. 08/05/2020 and 08/11/2020 at around 1pm LPA obtained copies of the Activity Calendar, Personnel Report LIC 500, Resident Roster and a copy of the facility approved Admission Agreement.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200731141815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE SANTA MONICA GARDENS	FACILITY NUMBER: 197606682
	VISIT DATE: 08/13/2020

NARRATIVE

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The investigation revealed the following: On 08/05/2020 LPA interviewed Administrator Ralph Balbin and Activities Director who stated that activities have been slowed down but not taken away from the residents. Administrator states that residents are not happy that they cannot gather in a group for their activities. Activity Director Ashley Shire stated bingo, reading, limited walking, zoom games were being offered 3 times a week.

On 08/12/2020 LPA interviewed residents R1 to R10, 10 out of 10 Residents stated that prior to Covid-19 there were many activities for residents and after Covid-19 there was very limited activities offered by the facility. As of 8/17/2020 Current guidance from Centers from Disease Control stated to limit group activities to prevent the spread of COVID-19 per DPH order #0B20201190

“We have found the complaint allegation “Staff do not have planned activities for residents while in care” unsubstantiated, although the allegation may have happened or is valid; there is not a preponderance of the evidence to prove that the alleged violation occurred.

A telephonic exit interview was conducted with Administrator Ralph Balbin, and a hard copy was provided via email for signature. “

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2020

LIC9099 (FAS) - (06/04)

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