197606682-2-2-2024-11-AS-UCOL-D36QTG-20240308112708

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606682
Report Date: 02/02/2024
Date Signed: 02/02/2024 04:07:11 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, 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
01/29/2024 and conducted by Evaluator Regina Cloyd

COMPLAINT CONTROL NUMBER: 11-AS-20240129223753

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:	08:56 AM
MET WITH:	Business Manager Ashley Fernandez		TIME COMPLETED:	04:16 PM

ALLEGATION(S):

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Staff did not issue a refund.

INVESTIGATION FINDINGS:

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On 02/02/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegations. LPA met with Business Office Manager Ashley Fernandez and Executive Director Mia Nakamatzu (via zoom) and explained the purpose of the visit.

The investigation consisted of the following: During today’s investigation LPA interviewed 6 out of 60 residents and 5 staff which included the Executive Director, Business Manager, Resident Engagement Manager, MedTech, Concierge, and the Health and Wellness Director. LPA reviewed the register of residents, personnel reports (LIC 500), accounting documents, and resident records.

Continue to LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
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-20240129223753

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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

NARRATIVE

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The investigation revealed the following: Regarding the allegation "Staff did not issue a refund," Record reviews indicate that R1 and R2 was refunded their community fee according to the terms of the signed admission agreement. LPA observed on page 8 Section IV(B) states, You may terminate this Agreement upon thirty (30) days written notice to the facility. Termination occurs on the later of the end of the notice period or upon the removal of all of your personal belongings. Records reviews indicate that on 09/09/23, R1 submitted a written notice that R1 and R2 would move out of the facility on 09/13/23 and the medical bed would be removed on 09/14/23. LPA observed on page 6 Section III(A)(3) states, “If you complete a pre-admission appraisal (personal service assessment), five hundred dollars ($500) of the Community Fee becomes non-refundable, with the remainder of the Community Fee (“Refundable Amount”) subject to the following refund rules: (2) Once you enter the Community, if this Agreement terminates and you leave for any reason within the second month of residency, you are entitled to a refund of sixty percent (60%) of the Refundable Amount. Record reviews indicate that R1 and R2 received a refunded community fee on 10/06/23 and the credit was applied to the account balance. Interviews with the Executive Director and Business Manager indicate that Accounting mailed the remaining credit balance on 10/10/23. Interviews conducted indicated the following: Five out of five staff interviews disagreed with the allegations. One staff member was unavailable for the interview. Five out of six residents interviewed disagreed with the allegations. Regarding the allegation "Staff did not issue a refund,” the investigation revealed that a refund was issued. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated.

No deficiencies were cited. An exit interview was conducted. A copy of this report was reviewed and provided to the Business Manager Ashley Fernandez.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
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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