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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606682
Report Date: 07/25/2023
Date Signed: 01/31/2024 10:52:23 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
07/19/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230719084523
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: 62DATE:
07/25/2023
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Mia Nakamatzu, Executive DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility does not have sufficient staff to meet the needs of the residents.
Staff are not adequately communicating with residents regarding updated information.
INVESTIGATION FINDINGS:
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On 01/31/24 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced visit to deliver this amended document and was met by Mia Nakamatzu, Executive Director.
On 07/25/23, LPA conducted an unannounced, subsequent, complaint visit to the facility. LPA was met by Dimple Kamdar (DK), Operations Specialist, and later by Callie Michael (CM), District Director of Clinical Services, who were informed that this visit was conducted to investigate the allegations listed above, previously initiated on 07/24/23.

On 07/24/23, LPA conducted a tour of the facility and observed no urgent issues. LPA requested facility documentation and reviewed the documents provided. LPA interviewed 5 (five) residents and 4 (four) staff.

On 07/25/23, LPA requested further facility documentation and reviewed the documents provided. LPA interviewed two (2) residents and two (2) staff.
Report continues, see LIC9099C.
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
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 5
Control Number 11-AS-20230719084523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE SANTA MONICA GARDENS
FACILITY NUMBER: 197606682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition..residents in privately operated residential care facilities for the elderly (RCFE) shall have all of the following personal rights:
(4) To care..and services..meet..needs
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LPA and S1 have agreed that the facility will have a new Class B driver on, or prior to, the POC due date (08/29/23) in order to support the residents to be able to enjoy their lunch, shopping and sightseeing outings. This will also allow S4 to better focus on their duty.
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..delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This deficiency has not been met as evidenced by:
S3 has changed position as of 04/27/23, requiring S4 to stand-in which limits S4 duty.
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 S1 will keep LPA informed as to the next hire date(s) of the future transportation, caregiving, wellness, and executive director departments' staff(ing) via email at Mario.Leon@DSS.CA.GOV.
Type B
07/25/2023
Section Cited
CCR
87468.2(a)(7)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) ..residents in privately operated RCFE shall have..following personal rights:
(7) To fully participate in..communications regarding care and services provided, according to Health and Safety Code
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LPA and S1 have agreed that the facility will continue to improve their management skills in order to better provide detailed information regarding various questions that will arise from the residential community. The facility will ensure that all new staff will remain proactive in communications with the
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1569.80..in this planning. The licensee shall provide necessary information and support to..residents..maximum extent possible,.. enabled to make informed decisions..choices.
This has not been met as evidenced by:
Facility has been lacking a stable Executive Director since 04/29/23
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current and future resident community.
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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
07/19/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230719084523

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: 62DATE:
07/25/2023
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Dimple Kamdar, Operations SpecialistTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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2
3
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9
Staff are not following resident's care plan.
Staff does not respond to resident's calls for assistance in a timely manner, or not at all.
INVESTIGATION FINDINGS:
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On 07/25/23, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced complaint visit to the facility. LPA was met by Dimple Kamdar (DK), Operations Specialist, and later by Callie Michael (CM), District Director of Clinical Services, who were informed that this visit was conducted to investigate the allegations listed above, previously initiated on 07/24/23.

On 07/24/23, LPA conducted a tour of the facility and observed no urgent issues. LPA requested facility documentation and reviewed the documents provided. LPA interviewed 5 (five) residents and 4 (four) staff.

On 07/25/23, LPA requested further facility documentation and reviewed the documents provided. LPA interviewed two (2) residents and two (2) staff.

The report continues, see LIC9099-C
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20230719084523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BROOKDALE SANTA MONICA GARDENS
FACILITY NUMBER: 197606682
VISIT DATE: 07/25/2023
NARRATIVE
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The investigation revealed the following:

Regarding the allegation: "Staff are not following resident's care plan.” Six (6) out of seven (7) resident interviews have denied this allegation. All six (6) staff interviews have denied the allegation. LPA's observation and the facility’s internal records indicate that there are monthly logs being conducted and followed. Although the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation did, or did not, occur. Therefore the allegation is "Unsubstantiated".

Regarding the allegation: "Staff does not respond to resident's calls for assistance in a timely manner, or not at all." Four (4) out of seven (7) resident interviews have denied this allegation, while two (2) resident interviews have noted indifference at the wait in response time. All six (6) staff interviews have denied the allegation and all six (6) concur that there is a one-minute electrical response in which staff must use a special key around their neck to turn off the electrical alarm. LPA has also observed all staff wearing a pager and two-way radio for immediate communication. Although the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation did, or did not, occur. Therefore the allegation is "Unsubstantiated".

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20230719084523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BROOKDALE SANTA MONICA GARDENS
FACILITY NUMBER: 197606682
VISIT DATE: 07/25/2023
NARRATIVE
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The investigation revealed the following:

Regarding the allegation: "Facility does not have sufficient staff to meet the needs of the residents." All seven (7) resident interviews have agreed with the above allegation, while three (3) out of six (6) staff interviews agree with the above allegation. LPA has reviewed documentation which notes that the last permanent transportation driver moved positions as of 04/27/23 while the last long-term executive director worked as of 04/29/23 and lastly the health and wellness director and coordinator on 07/07/23 and 07/20/23, respectively, which left the organization unstable. There has been stand-in executive directors and health and wellness director, supporting the community in the meantime and will continue to support the community until a permanent health and wellness director will begin training on 7/31/23. In addition, 8 hours per shift for care giving will be available 08/01/23. LPA has observed advertisements for the various positions listed, yet these positions have been vacant for a time and criminal clearances must be obtained prior to staff working on-site. Based on interviews, record reviews and observations conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.

Regarding the allegation: "Staff are not adequately communicating with residents regarding updated information." Five (5) out of seven (7) resident interviews have agreed with the above allegation, while two (2) out of six (6) staff interviews agree with the above allegation. Interviews indicate that lack of direction from executive staff led to the facilities’ inability to follow through at providing an updated illness status to residents. Based on interviews, record reviews and observations conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.



On 07/25/23, an exit interview was conducted and plans of corrections were developed with Dimple Kamdar, Operations Specialist. A copy of this report and appeal rights have been provided.

On 01/31/24, an exit interview was conducted with Mia Nakamatzu, Executive Director. A copy of this report and appeal rights have been provided.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5