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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606682
Report Date: 06/26/2024
Date Signed: 06/26/2024 04:50:53 PM


Document Has Been Signed on 06/26/2024 04:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 GARDENSFACILITY NUMBER:
197606682
ADMINISTRATOR:RALPH BALBINFACILITY TYPE:
740
ADDRESS:851 2ND STTELEPHONE:
(310) 393-2260
CITY:SANTA MONICASTATE: CAZIP CODE:
90403
CAPACITY:128CENSUS: 57DATE:
06/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Mia NakamatzuTIME COMPLETED:
05:00 PM
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On 06/26/2024, Licensing Program Analyst (LPA) David España conducted an unannounced annual required visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA met with staff and explained the purpose of today’s visit. LPA was granted entrance to the facility. The facility is an RCFE licensed for one-hundred and twenty-eight (128) non-ambulatory and also includes a hospice waiver for (10) ten. Currently, there are 57 residents residing in the facility, all are over the age of 59 or older. LPA was later joined on the visit by Facility Mia Nakamatzu. The facility is a four-story structure located in a residential neighborhood. It consists of the following: ninety-two (92) resident rooms with attached bathrooms, dining area, kitchen, garage, library, activity room, gym, front garden with two outdoor covered areas in which there are tables and chairs, and a back outdoor covered area in which there are also tables and chairs. LPA España and Mia Nakamatzu toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided was provided in residents rooms and storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. LIC809-C Continued
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/26/2024
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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage for area cleaning supplies, toxins, and sharps objects was observed and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Smoke detectors were observed in client rooms and are connected to the fire department.

LPA reviewed Medication Administration Record (MAR) and observed it to be maintained in order and accurate. During the visit, LPA observed the facility's infection control practices. All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a hard copy of this report was provided to Mia Nakamatzu.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
LIC809 (FAS) - (06/04)
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