197606682-1-24-2024-11-AS-MVAO-D3DRVP-20240315132151

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606682
Report Date: 01/24/2024
Date Signed: 01/24/2024 03:24:00 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
10/05/2023 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20231005145936

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:	01/24/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mia Nakamatzu		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff failed to safeguard resident's personal property
Resident is being financially abused at the facility.

INVESTIGATION FINDINGS:

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On 01/24/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent complaint visit to the facility listed above. LPA met with Executive Director, Mia Nakamatzu, and the purpose of today's visit was explained.
During today's visit LPA conducted a facility tour and interviewed Resident R2 and Staff S1 and S7.

LPA visited the facility on 10/12/23 and toured the facility and received copies of documents pertinent to the investigation. The documents received and reviewed were the Staff Roster, Resident Roster, Admission Agreement for resident, Physicians Report, Needs and Service Plans, Additional Service Charges, list of residents receiving oxygen, Theft and Loss Policy, and Resident Theft and Loss Log. On 11/30/23 LPA toured the facility and interviewed Staff (S2-S5) and Resident (R1-R5)

The investigation revealed the following:
Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

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 4

Control Number 11-AS-20231005145936

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: 01/24/2024

NARRATIVE

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Allegation: Staff failed to safeguard resident’s personal belongings.
The allegation alleges that there has been theft of items.
During interviews with Residents (R1-R6), four (4) out of six (6) stated they have had no items go missing, nor do they have any concerns regarding staff safeguarding their belongings. Resident R1 stated they have had some items go missing, some they were able to find, and others are gone. Additionally, R1 stated one of the missing items was explained by staff why the item was removed from their room, due to it being a health and safety issue. Resident R6 stated they have had a few items go missing such as clothing, but it is not something they are concerned about. During interviews with Staff (S1-S6) six (6) out of six (6) stated when a resident reports a missing item, staff will assist the resident in searching their room, common areas, and staff will check the laundry room. Staff S1 stated if the item is not found staff who were working at the time the item went missing will be questioned if they have seen it and the family will be notified. Additionally, S1 stated there has been times when they notified the families of the missing item, the family will inform them their resident had donated the item weeks ago or has gotten rid of it. During an interview with Staff S2 and S3, stated R1 had an item removed from their room while they were in the hospital due to it being a health and safety risk, and they informed R1 upon return to the facility. During review of the Resident Loss and Theft Log, LPA observed that some of the items that were reported missing by R1 were found in R1’s room. During review of residents Admission Agreement, LPA observed it states on page 12, number 9. “We make no representations or guarantees that we can prevent the loss of personal item…We will not be responsible for the loss of such items unless such loss is due to our

Continued on LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 11-AS-20231005145936

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: 01/24/2024

NARRATIVE

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negligence or misconduct. We make no representations or guarantees that we can prevent theft or other criminal acts perpetrated by another resident or person; therefore, we recommend that valuables such as jewelry and large sums of money, not be kept at the community. If you choose to bring valuables, you do so at your own risk and we will not be held responsible for any theft or loss of such items, unless such loss is due to our negligence or misconduct or the negligent or misconduct of our associates.” Additionally, during file review of R1's file, LPA observed that R1's Safeguard of Property/Valuable was signed but they did not fill it out. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Resident is being financially abused at the facility.

The allegation alleges the facility is overcharging for essentials such as oxygen, caregiving, electric bed and wheelchair equipment and transportation services. During interviews with Residents (R1-R6), four (4) out of six (6) stated they have not been overcharged for services and have no concerns regarding the charge for services they receive. Resident R1 stated they were charged for services they did not receive while they were in the hospital. Resident R6 stated they feel the facility charges too much for services. During interviews with Staff S1 and S2, two out of two stated when a resident is admitted to the facility an assessment of the resident is conducted and the services they need or want are discussed. The residents are able to select or deny the services they require or want. Resident’s bills are based

Continued on LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20231005145936

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: 01/24/2024

NARRATIVE

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on the service they select. Additionally, Staff S1 and S2 stated that even if the Resident is in the hospital that rent and service fees are still charged per the Admission Agreement. During file review, LPA reviewed the Resident’s Admission Agreement that states on page 7, C. Absence, Fees During Absence. “If you are absent from the Community for any reason, such as, for a hospitalization, vacation, temporary nursing home care or rehabilitation, the Residency Agreement will remain effective and you will be charged the full Monthly Service Rate.” During an interview with Resident R1, they stated they wanted a new mattress and when they called the company to order just a mattress the company stated they do not sell just the mattress and they would need to purchase the entire bed (hospital bed). LPA reviewed the receipt for the purchase and the company is not associated with the facility. During an interview with Resident R1, they stated they got a new wheelchair that their insurance covered, and the new wheelchair broke they ordered a new one and they were charged for it. LPA reviewed the receipt for the wheelchair and the company is not associated with the facility. During file review of Residents R1 and R2’s Admission Agreement, LPA reviewed the services selected and reviewed their monthly billing statement and upon review LPA observed the costs and amounts to be consistent. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated.

During today's visit LPA did not observe or cite any deficiencies.

An exit interview was conducted with Executive Director, Mia Nakamatzu, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC9099 (FAS) - (06/04)

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