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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606682
Report Date: 05/16/2024
Date Signed: 05/16/2024 11:20:56 AM

Substantiated


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
11/21/2023 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20231121145936
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:
05/16/2024
UNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Milca OsorioTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility's signal system did not produce an auditory signal loud enough to summon staff.
Lack of supervision
INVESTIGATION FINDINGS:
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On 05/16/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced visit to the facility listed above to deliver findings for the above allegations. LPA met with Health and Wellness Director, Milca Osorio, and the purpose of today’s visit was explained.

During a previous visit conducted on 11/30/23, LPA toured the facility and received copies of documents pertinent to the investigation. The documents received and reviewed were the Staff Roster, Resident Roster, resident Physicians Report, Needs and Service Plans, and recent training logs. LPA interviewed residents (R2-R6) and staff (S1-S5).

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
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-20231121145936
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: 05/16/2024
NARRATIVE
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Allegation: Facility signal system did not produce an auditory signal loud enough to summon staff.
It is alleged Resident R1 was not feeling well in the middle of the night and pressed the medical alert button, but nobody came. R1 then called the front desk, and nobody answered the phone.
During an interview with R1’s Responsible Party (W1) stated facility staff left them a voicemail stating the battery was low in R1’s pendant. Additionally, W1 stated when they brought R1 back from the hospital the following afternoon the facility’s phone system was still down. During interviews with Staff (S1 and S2), two (2) out of two (2) stated there was an issue with the phones on December 12, 2023, and that the phone system has gone down in the past. S1 stated there has been a new procedure implemented for when the phone system goes down and for the medical alert pendant to inform them when batteries are low on a resident’s pendant. During interviews with Residents (R1-R6) two (2) out of six (6) stated there has been times when they press their pendant for assistance and had to wait an extended period of time before a caregiver arrived and they received care. R6 stated there was a time they had to wait three (3) hours before assistance came. R1 stated that having to wait for assistance commonly occurs in the evenings and nights. During interviews with staff (S1-S7) seven (7) out of seven (7) stated they receive training annually regarding the medical alert pendants and had a training regarding the new procedures implemented regarding low batteries in pendants and the telephones when down.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20231121145936
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: 05/16/2024
NARRATIVE
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During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

Allegation: Lack of supervision.


It is alleged that a resident fell in the night and waited for staff to help them till the morning when their breakfast was delivered.
During interviews with Staff (S1-S7) seven (7) out of seven (7) stated rounds are to be done every two (2) hours per shift. Additionally, S2 stated if a resident is a fall risk or has recently returned from the hospital rounds are done hourly to check on that resident. During an interview with S3 stated there are some residents who prefer not to be checked on in the evenings. S3 marked the Resident Roster indicating which Residents do not want to be checked during the Noc shift. Upon review of that list, LPA observed R1 was not indicated on that list. During file review of Resident R1, LPA observed on the Physicians Report R1 needs medical supervision for fall precautions and on the Assessment Summary it is noted R1 has fallen in the past twelve months. During interviews with Residents (R1-R6), three (3) out of six (6) stated Staff come and check on them during the day. Additionally, during an interview Resident R1 stated staff comes and checks on them a limited number of times during the day. LPA asked R1 if they had any falls recently, R1 stated they had a fall, but they were doing much better. During an interview with
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20231121145936
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: 05/16/2024
NARRATIVE
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R1’s Responsible Party (W1) stated R1 fell during the night, pressed their medical alert pendent at 4am, and called the front desk for assistance and could not get assistance. W1 stated R1 was able to pull themselves off the floor and waited until their breakfast was brought to them around 8:30am.

During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

Deficiencies are cited on the attached LIC9099-D.

An exit interview was conducted with Health and Wellness Director, Milca Osorio, and a copy of this report and appeal rights was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20231121145936
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2024
Section Cited
CCR
87303(i)(1)
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87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or building shall have a signal system which shall: transmit a visual and/or auditory signal
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Administrator will ensure that resident pendants are charged and implement a plan for when pendants are not working or when the phones go down. Administrator will fax a copy of the plan and training logs to LPA.

Att. LPA Gibbs (424)544-1016
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to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.
This regulation was not met, based on interviews, staff did not ensure resident’s alert pendant signaled to staff to summon them to provide assistance.
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Type B
05/30/2024
Section Cited
HSC
1569.312(e)
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1569.312 Basic Services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.
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Administrator will conduct training for staff regarding conducting resident checks every 2-hours. Administrator will fax a copy of the staff sign-in for the training and any training material used.
Att. LPA Gibbs (424)544-1016
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This regulation was not met, based on record review, and interviews the Administrator did not comply with this regulation and a fall risk resident R1 was not monitored through the night.
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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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5