197606682-6-19-2023-11-AS-ARID-CSXV5V-20230619160833

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606682
Report Date: 06/19/2023
Date Signed: 06/19/2023 04:08:52 PM

Document Has Been Signed on 06/19/2023 04:08 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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: 67	DATE:	06/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:14 AM
MET WITH:	Julie Manzanares		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/19/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with business manager Julie Manzanares 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 (67) residents residing in the facility, all are over the age of 59 or older. LPA was later joined on the visit by executive director Matan Burstyn. 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 Richard and Manzanares 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. The hot water temperature tested 117. 9F degrees. 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. LPA observed screening protocols for visitors, staff, and residents as well as sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff tests and residents' vaccination records along with daily temperature checks were conducted. The facility has an approved Mitigation Plan Report on file with CCLD.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE SANTA MONICA GARDENS	FACILITY NUMBER: 197606682
	VISIT DATE: 06/19/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA advised the business executive to create more activities, so residents would have more choices and events to attend.

According to the California Code of Regulations Title 22. During today's visit there was a deficiency observed. There was no administrator available at the facility. Administrator Certification Requirements or the Recertification Requirements in section 87407, Administrator recertification Requirements.

An exit interview was held. A copy of the report and appeal rights were provided to business executive Julie Manzanares

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 06/19/2023 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE SANTA MONICA GARDENS	FACILITY NUMBER: 197606682
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2023
	Plan of Correction
1 2 3 4	The licensee will submit a plan of correction and documentation that an administrator has met the certications specified in Section 87406 to LPA Antonine.Rchard@dss.ca.gov via email. (323) 516-4092

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4