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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606682
Report Date: 03/21/2022
Date Signed: 03/21/2022 03:34:47 PM

Unsubstantiated


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
03/17/2022 and conducted by Evaluator Jade Jordan
COMPLAINT CONTROL NUMBER: 11-AS-20220317142819
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: 67DATE:
03/21/2022
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Ralph BalbinTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility did not provide adequate supervision to resident's
INVESTIGATION FINDINGS:
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On 03/21/22 Licensing Program Analyst (LPA) Jade Jordan Conducted an Unannounced visit to conduct a complaint investigation regarding the allegation(s) above. LPA was met by Facility Administrator Ralph Balbin, and the purpose of the visit was explained.

The investigation consisted of: Interviews with staff and residents, Record Review of Physicians Report, Needs and services, Brief Interview for Mental status.

Regarding Allegation: Facility did not provide adequate supervision to residents.
Complaint Report by Reporting Party indicated that Resident 1 (R1) is isolating Resident 2 (R2) from family caregivers, and solicitating funds. Interviews with Direct Caregiving Staff revealed that they believe R1 is controlling in nature, but not isolating R2 from other residents. Caregiving Staff generally stated that they have not witnessed R1 ask R2 for money. Interviews conducted with R2 stated that they are not being by isolated by R1.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
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 2
Control Number 11-AS-20220317142819
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: 03/21/2022
NARRATIVE
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R1 and R2 Stated that they are in a consensual friendship and are enjoying each other’s company. R2 stated that they enjoy other activities outside of R1, such as Yoga and reading. R2 and R1 both stated that R1 is not soliciting money. R1 stated that they have been encouraging R2 to become a stronger person and encouraging R2 to take back their financial freedom. Interview conducted with Residents who know R1 and R2, generally stated that they do not feel R1 isolates R2, and they have no witnessed R1 solicit funds from R2. Record Review revealed that R2 does not have any diagnosis of dementia, or mild cognitive impairment, hindering them from making decisions. Administrator stated that R1 and R2 are aware of their personal rights, and have had their own internal discussions with the residents to ensure adequate supervision is provided.
Based on Interviews, Record Review and Observation.

The LPA finds that Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2