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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606682
Report Date: 08/12/2020
Date Signed: 08/13/2020 09:33:29 AM



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 GARDENSFACILITY NUMBER:
197606682
ADMINISTRATOR:RALPH BALBINFACILITY TYPE:
740
ADDRESS:851 2ND STTELEPHONE:
(310) 393-2260
CITY:SANTA MONICASTATE: CAZIP CODE:
90403
CAPACITY:128CENSUS: 69DATE:
08/12/2020
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ralph Balbin AdministratorTIME COMPLETED:
03:58 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
 Staff do not have planned activities for residents while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/11/2002 around 2pm licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation for the allegation listed above. 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 facility administrator.

LPA Calderon conducted telephone interviews via face time with 10 out of 69 residents.

A telephonic exit interview via face time was conducted with Ralph Balbin Administrator, and a hard copy was provided via email for signature.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2020
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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