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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606682
Report Date: 01/25/2024
Date Signed: 01/25/2024 10:52:38 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, 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
07/26/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20230726082709
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: 65DATE:
01/25/2024
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:ADMINISTRATOR RALPH BALBINTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff do not provide adequate activities for residents
INVESTIGATION FINDINGS:
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THIS REPORT SUPERSEDES THE REPORT DATED 08/2/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: SUBSTANTIATED
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Brookdale Santa Monica Gardens on 08/02/2023 and was greeted by Operations Director Dimple Kamdar (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

During this investigation, LPA Calderon interviewed A1, S1, R1-R7. This interview was conducted on 08/02/2023. On 08/02/2023 LPA Calderon requested copies of the following: Staff LIC500 and Resident rosters, needs and service, physician report, admission agreement, any incident reports for R1 and the monthly activities calendar for the facility.

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

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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-20230726082709
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: 01/25/2024
NARRATIVE
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Regarding Allegation #1: Staff do not provide adequate activities for residents.

The alleged staff did not provide adequate activities for residents in care. On 08/02/2023 LPA Calderon interviewed A1 for a complaint. A1 reported that S1 must work as facility driver and activities director and that this does affect residents’ activities. A1 reported that the facility does provide a monthly activities calendar but, due to staffing issues, most activities are not done. A1 relays that more interactive activities need to be offered to residents in care. On 08/02/2023 LPA Calderon interviewed S1 for complaint. S1 claimed that the facility lets go of the facility driver and S1 assistant. S1 expressed that S1 did not know if S1 had to drive residents, and this affected if S1 was able to give activities to residents. S1 stated that there are not enough staff to provide activities to residents in care. On 08/02/2023 LPA attempted to interview R1, but R1 left the facility for the day. On 08/02/2023 LPA Calderon interviewed R2-R8 for complaint. R7 relays that R7 loves the activities provided by staff and has no issues. R2-R6 and R8 stated that the activity director is the best S1 can do and there are not enough interactions with staff and activities that make the residents think. R2-R6 and R8 relay that the community calendar is not followed by staff and the administrator is aware of this situation. On 08/02/2023 LPA Calderon reviewed the community calendar with all residents and residents could not pick out what activities they loved to do; most activities were not attended.



Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation “staff do not provide adequate activities for residents” is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Operations Director Dimple Kamdar (A1).
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20230726082709
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2024
Section Cited
CCR
87219(a)
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87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement is not met as evidenced by:
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The administrator will adhere to Title 22 Reg 87219(a) and provide a plan on how to address sufficient activities for the facility for residents in care. POC will be presented to the CCL by due date: 02/01/24 by email to LPA Calderon at: Jose.Calderon@dss.ca.govThe administrator will adhere to Title 22 Reg 87219(a) and provide a plan on how to address sufficient activities for the facility for residents in care. POC will be presented to the CCL by due date: 02/01/24 by email to LPA Calderon at: Jose.Calderon@dss.ca.gov
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Based on interviews, observations and records the licensee failed to ensure that the facility has a active activity planner that all residents attend. This poses a potential health & safety risk to resident in care.
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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: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
07/26/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20230726082709

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: 65DATE:
01/25/2024
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:ADMINISTRATOR RALPH BALBINTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff prevent residents from having visitors during reasonable hours
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
THIS REPORT SUPERSEDES THE REPORT DATED 08/2/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: UNSUBSTANTIATED
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Brookdale Santa Monica Gardens on 08/02/2023 and was greeted by Operations Director Dimple Kamdar (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

During this investigation, LPA Calderon interviewed A1, S1, R1-R7. This interview was conducted on 08/02/2023. On 08/02/2023 LPA Calderon requested copies of the following: Staff LIC500 and Resident rosters, needs and service, physician report, admission agreement, any incident reports for R1 and the monthly activities calendar for the facility.

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

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20230726082709
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: 01/25/2024
NARRATIVE
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Regarding Allegation #1: Staff prevent residents from having visitors during reasonable hours.

The alleged staff prevent residents from having visitors during reasonable hours. On 08/02/2023 LPA Calderon interviewed A1 for complaint. A1 relays that the facility has an admission agreement which R1 signed. A1 relays that all visitors, guests, and family are welcome to visit. A1 relays that no visitor, guest, or family can stay over night and the facility does not discriminate against a resident with health issues. On 08/03/2023 LPA Calderon attempted to interview R1 for complaint, R1 left the facility for the day. On 08/02/2023 LPA Calderon interviewed R2-R8 for complaint. R2-R8 relays that no visitor, guest, or family can stay overnight, and all visitors, guest and family are welcome and R2-R8 have never had any issues. On 08/02/2023 LPA Calderon reviewed the residency agreement signed by R1 family on 05/28/2023. The agreement does not suggest a time a guest, visitor or family can arrive at the facility or leave the facility. Overnight guests are generally not permitted in a resident’s room.

Based on evidence gathered from investigation there is insufficient evidence to prove that “staff prevent residents from having visitors during reasonable hours”, therefore the allegation is unsubstantiated.

An exit interview was conducted and copy of the Complaint Report was provided to the Operations Director Dimple Kamdar (A1).

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

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5