197606682-2-5-2024-11-AS-JHAD-D2NTVJ-20240221140402

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606682
Report Date: 02/02/2024
Date Signed: 02/05/2024 12:34:56 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2024 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240111081540

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: 60	DATE:	02/02/2024
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Ashley Fernandez & Milca Osorio		TIME COMPLETED:	03:49 PM

ALLEGATION(S):

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Facility staff did not provide resident's representative with a statement itemizing all separate charges incurred.

INVESTIGATION FINDINGS:

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On 02/01/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit to this facility. Upon arrival at the facility, LPA Dabuet was greeted by Business Manager Ashley Fernandez. Fernandez contacted Executive Director Mia Nakamatzu who was available through virtual communication. The purpose of the visit was provided to Nakamatzu to investigate the allegation mentioned above.

The investigation consisted of the following: Interview conducted with the Executive Director, Wellness Director, and Licensed Vocational Nurse. Inquiry questions were relevant to the nature of the complaint. Record reviews of documents of staff and residents’ roster (R1's) ID/Emergency Information, Preplacement Appraisal, In-House Service Assessment, and other pertinent documents associated with this complaint. A tour of the facility was conducted.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

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-20240111081540

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BROOKDALE SANTA MONICA GARDENS	FACILITY NUMBER: 197606682
	VISIT DATE: 02/02/2024

NARRATIVE

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INVESTIGATION REVEALED FOLLOWING:

Allegation: Facility staff did not provide resident's representative with a statement itemizing all separate charges incurred.
The details of the complaint reported the facility failed to provide resident #1 (R1) representative with itemized charges. The complainant reported (R1) was provided with a rate increase of $2,000.00 for an increase of care and did not provide the itemized charges. The complainant claimed that (R1) was contracted for $6094.00 for basic services based on (R1's) needs and services were agreed upon under the contract. The complainant claimed there was no agreement for the additional rate increase of $2,000.00. A request for additional information and supporting documents, the complainant was unable to provide.

Resident #1 (R1's) residency began effective 05/30/23. A Residency Agreement between Brookdale Santa Monica Gardens and the legal representative for (R1) (dated on 05/26/23) was signed on 05/28/23. Included in the Residency Agreement are the terms and conditions of the agreement. It specified the Services and Accommodations. The Basic Services included: Accommodation, Dining Service, Utility Services, Housekeeping Service, Laundry and Linen Service, Activities Program, Transportation, Staffing 24-hr daily, Observation and Consultation, and Assistance with Access to Outside Services. The Personal Services (outlined in Exhibit Z of the Residency Agreement contract). In Exhibit Z these services are additional charges not included within the Basic Services and it is based on (R1's) medical assessment and needs and service plan defined as follows: Medications (assistance with medications), Chronic Condition Management (specific care and/monitoring by nurse or care associate for more complex insulin), Nutrition (assistance with planning, preparing or/monitoring nutritional needs), and Service Coordinator. Medication (assistance with scheduling medical/dental or lab appointments). The Residency Agreement included the itemized charges listed on Exhibit A with the following: Community Fee before Move-In of $5000.00, Basic Service Rate of $6505.00, and Personal Service Rate of $1211.00 (itemized in Exhibit Z). In the Addendum to the Residency Agreement Personal Service Rate Maximum Pricing, is outlined under the Personal Service Plan Service Rate Maximum of $7965.00. Under an Addendum to the Residency Agreement Permanent Basic Service Rate Discount, "The Community agrees to discount the Basic Service Rate of $6505.00 by $1626.00 (discount)". According to the Residency Agreement agreed between (R1's) legal representative and Brookdale Santa Monica Gardens (dated: 05/26/23), it indicated itemized charges of the Basic Service Rate $6505.00, Basic Services Discount $1626.00, and Personal Service Rate
(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240111081540

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BROOKDALE SANTA MONICA GARDENS	FACILITY NUMBER: 197606682
	VISIT DATE: 02/02/2024

NARRATIVE

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(medication management $1101.00, chronic condition management $1982.00, nutrition $330, and service coordinator $110.00) for a total of $8402.00. A signature of acknowledgement from (R1's) legal representative (dated: 05/28/24) validated this is a legal contract, and a legal copy was provided to (R1's) legal representative.

On 01/17/24 between 10:00 am - 01:41 pm, the Department interviewed (2) out (2) staff #1-#2 (S1-S2) and stated were both unaware if a request for a statement itemizing all separate charges incurred was ever requested for (R1). (S1-S2), however, provided the Department documentation records for (R1) with the following Residency Agreement (dated: 05/26/23), Assessment Summary (dated: 05/23/23 - 06/20/23, Account History Report (dated: 08/06/23 and 01/17/24), Account Balance Activity (dated: 06/16/23-07/14/23-09/14/23-11-16-23, and 11/30/23) and an internal written communication reference to (R1) were issued.

On 02/02/24 between 11:54 am - 12:12 pm, the Department interviewed staff #3 (S3). (S3) identified in the complaint as the business manager is not the business manager, and (S3's) role is the Clinical Specialist/License Vocational Nurse and had nothing to do with residents' charges. (S3's) role was to assist with residents' care with more complex programs. (S3) claimed there were numerous conversations related to (R1's) personal service but does not recall a request for a statement itemizing all separate charges incurred for (R1). (S3) disclosed the medical assessment was performed before (R1) moved in, and it remained the same throughout (R1's) residency at the facility. (S3) communicated that in no circumstances would additional fees for services would be charged without an agreement with the resident or the resident's legal representative. The Department obtained an internal progress note (dated: 08/10/23) of a discussion on a conference call on 08/09/23 with (R1's) legal representative, (S3), and with former Executive Director. The discussion related to (R1's) Care Plan and Medication Management and the Chronic Condition charges was disputed. There was no mention of a statement request for itemized charges. Based on the information provider, an inspection of the facility, observation, interviews, and analysis of records, the Department found no evidence to support the allegation mentioned above.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

An exit interview was conducted with Milca Osorio, and a copy of the report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

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