197606682-2-22-2021-11-AS-JHAD-BYXQCK-20210309110317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606682
Report Date: 02/22/2021
Date Signed: 02/22/2021 03:13:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/22/2020 and conducted by Evaluator Ulysses Coronel

COMPLAINT CONTROL NUMBER: 11-AS-20200622104251

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: 62	DATE:	02/22/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ralph Balbin		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident sustained multiple fractures while in care.
Resident sustained multiple pressure injuries while in care.
Lack of supervision resulting in resident sustaining multiple falls.

INVESTIGATION FINDINGS:

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On 02/22/21 at 1:00 PM, Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation to deliver the investigation findings for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Executive Director Ralph Balbin.

The complaint investigation consisted of the following: On 06/23/2020 LPA Coronel initiated a complaint investigation and conducted a virtual tour of the facility. The LPA also requested copies of the facility and resident records.RO referred the complaint to the Investigations Branch and it was assigned to Special Investigator 06/22/2020. On 09/29/2020 IB interviewed Executive Director Ralph Balbin and facility staffs S1, S2 and S3. On 09/30/2020 IB interviewed R1’s family F1. On 10/05/2020 IB interviewed facility staff S4. On 10/06/2020 IB reviewed R1’s hospital medical records

Report continues, please see LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021

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-20200622104251

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE SANTA MONICA GARDENS	FACILITY NUMBER: 197606682
	VISIT DATE: 02/22/2021

NARRATIVE

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The complaint investigation revealed the following:
Regarding the allegation “Resident sustained multiple fractures while in care.” On 10/06/2020 record reviews of R1’s resident and hospital records did not indicate R1 sustaining multiple falls nor fractures at the facility prior to 06/10/2020. On 09/29/2020 facility staff S1 indicated that “R1 did not have any history of falls at the facility.” On 09/30/2020 R1’s family F1 stated that “R1 had several fractures from falls prior to living at the facility. Based on interviews and record reviews, there was no evidence to show that R1 sustained multiple fractures while in care. We have found the complaint allegation as Unsubstantiated; it means that although the allegation may have happened or is valid; there is not a preponderance of the evidence to prove that the alleged violation occurred.

Regarding the allegation “Resident sustained multiple pressure injuries while in care.” On 10/06/2020 R1’s hospital records indicate that on 06/10/2020, during physical examination R1’s skin was assessed for edema, rash and pressure injuries none were noted. On 10/06/2020 R1’s hospital records indicate that R1’s has a history of non-pressure non-healing ulcers on the right and left calves dating back to 07/05/2018” On 09/29/2020 facility staffs S1, S2 and S3 stated that, R1 suffered from skin injuries due to blood thinner medication. On 09/30/2020 R1’s family F1 stated that “If ever R1 had pressure injuries, it was probably because of the blood thinners R1 was on.” Based on interviews and medical record reviews, there was no evidence to show that R1 sustained pressure injuries at the facility. We have found the allegation as Unsubstantiated; it means that although the allegation may have happened or is valid; there is not a preponderance of the evidence to prove that the alleged violation occurred.

Regarding the allegation “Lack of supervision resulting in resident sustaining multiple falls.” On 10/06/2020 record reviews of R1’s hospital records did not indicate R1 sustaining multiple falls at the facility prior to 06/10/2020. On 09/29/2020 S2 stated that “All staff would keep a lookout on R1 and make sure that R1 was using R1’s walker or cane when walking.” On 09/30/2020 R1’s family F1 stated that “R1 did not have a history of falls at the facility.” Based on interviews and documents reviews, there is no evidence to show R1 sustaining multiple falls at the facility. We have found the complaint allegation as Unsubstantiated; it means that although the allegation may have happened or is valid; there is not a preponderance of the evidence to prove that the alleged violation occurred.

A hard copy was provided via email for signature.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021

LIC9099 (FAS) - (06/04)

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