197606682-8-21-2024-11-AS-SCIS-DB946G-20241121174931

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606682
Report Date: 06/06/2024
Date Signed: 08/21/2024 10:45:48 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/17/2024 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20240517084753

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: 56	DATE:	06/06/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Executive Director, Mia Nakamatzu		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff do not maintain accurate records.
Staff did not monitoring a resident's change in condition.
Resident left in soiled diapers for extended periods of time.
Staff are not allowing resident's responsible party to remove resident from facility

INVESTIGATION FINDINGS:

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*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 6/6/24.

On 6/6/24 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA arrived and spoke to the Executive Director, Mia Nakamatzu and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following: On 5/23/24, LPA Felisa Shirley conducted a review of Staff roster, Resident roster, and resident files. LPA Shirley conducted a tour of the facility for a health and safety check. LPA requested and received copies of Physicians report, emailed communications, dementia notice 4/25/23, and hospice notification, emails dated 1/2/24 and 5/10/24.

The investigation revealed the following:
Con’d on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

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-20240517084753

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/06/2024

NARRATIVE

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Allegation: Staff do not maintain accurate records

It has been reported that facility staff had no knowledge of a resident having dementia prior to 5/2024 as it was reported that a notice from UCLA was hand delivered in 2023 and was also emailed January 2024. Staff requested party to forward email of notice from UCLA that was allegedly sent to them 1/24, but notice was never received from the party and this party told Staff to check their emails for the notice. LPA observed an email dated 1/2/24 with attachments that did not contain any notice from UCLA Health. Notice for dementia was not received until 5/10/24. On 6/6/24 LPA observed an email dated 5/10/24 with attachments from UCLA Health re notification of dementia. It was also reported that facility staff did not have correct move out date for a resident. LPA observed a 30day notice dated 5/6/24, stating that resident will be out of the unit before 5/31/24. LPA observed an email dated 5/15/24 stating that the party will be changing moving date to next week, date TBD after meeting with attorney. On Friday 5/17/24, staff received email from the party stating that they have a crew coming next Sunday at 9am to remove resident’s items. The following Sunday’s date was 5/19/24, with no arrival of crew to collect resident’s belongings. Staff received another email from the party dated 5/20/24 stating that the MedCare transport will be coming Friday 5/24/24 at 10am. LPA interviewed staff S1-S6, LPA ask, does staff maintain accurate records. Of those interviewed, 5 out of 6 answered yes, and 1 staff that did not know. LPA interviewed residents R1 – R6, LPA ask, to your knowledge, does staff keep accurate records. Of those interviewed, 3 out of 6 answered yes and the other 3 did not know. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
Con'd on 9099-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20240517084753

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/06/2024

NARRATIVE

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Allegation: Staff did not monitor a resident’s change in condition

It is being reported that staff did not monitor residents change in condition, nor were family notified that resident had a change in condition. LPA learned that the resident was receiving home health through Remedy Home Health 11/2023. A new assessment was done and the resident went back on hospice services with Avila Hospice 1/4/24. Hospice staff never knew of family. Facility staff sent notice to CCLD regarding Hospice services 1/5/24. Staff notified, W1 about resident’s change in condition as W1 was the only contact person on record for emergencies. There was never any type of family contact with hospice services at all. The only family on record for emergency contact since admission was the resident’s son, who is now deceased. Facility staff could not update the party about residents medical condition as there was no POA on record nor a conservator. LPA interviewed staff S1-S6, LPA ask, does staff monitor residents for change in condition. Of those interviewed, 5 out of 6 answered yes, as 1 staff did not know. LPA interviewed residents R1 – R6, LPA ask, does staff monitor you for change of condition. Of those interviewed, 5 out of 6 answered yes, and 1 resident did not know. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Resident left in soiled diapers for extended periods of time

It was reported that a resident was left in soiled diapers for long periods of time and other residents providing this resident with incontinent supplies. During interviews,

Con'd on 9099-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20240517084753

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/06/2024

NARRATIVE

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LPA Shirley learned that residents are monitored and staff do frequent checks for residents with incontinence issues. This resident was also on Home Health services and then Hospice services in which both provided incontinence products to residents that are receiving services. Per S6, resident was not receiving incontinence products from other residents. Borrowing from other residents is not allowed. LPA interviewed staff S1-S6, LPA ask, are residents left in soiled diapers for extended periods of time. Of those interviewed, 4 out of 6 answered no as 2 staff did not know. LPA interviewed residents R1 – R6, LPA ask, have you ever been left in your diaper for an extended amount of time. Of those interviewed, 5 out of 6 answered no and 1 resident said yes. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated

Allegation: Staff are not allowing resident’s responsible party to remove resident from facility

It is being reported that family found another facility for the resident as the resident does not have the resources to stay at this facility. LPA Shirley learned through interviews that this resident does not want to leave this facility and has been vocal about it. S1 stated that she will honor the request for this resident to be relocated if the resident chooses to leave this facility without any refusal or struggle. Upon LPAs return to Brookdale, LPA learned that the resident left with no problems or resistance. LPA interviewed staff S1-S6, LPA ask, does staff allow resident’s responsible party to remove residents from this facility.
Con'd 9099-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20240517084753

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/06/2024

NARRATIVE

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Of those interviewed, 4 out of 6 answered yes and 2 staff did not know. LPA interviewed residents R1 – R6, LPA ask, is staff not allowing your responsible party to remove you from this facility. Of those interviewed, 3 out of 6 answered, yes and 3 did not know. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted and a copy of the LIC 9099 was provided to Executive Director, Mia Nakamatzu.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC9099 (FAS) - (06/04)

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