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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606682
Report Date: 08/02/2023
Date Signed: 08/02/2023 04:18:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
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:
08/02/2023
UNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:OPERATIONS DIRECTOR DIMPLE KAMDARTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not provide adequate activities for residents
INVESTIGATION FINDINGS:
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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) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BROOKDALE SANTA MONICA GARDENS
FACILITY NUMBER: 197606682
VISIT DATE: 08/02/2023
NARRATIVE
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SEE 812
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE SANTA MONICA GARDENS
FACILITY NUMBER: 197606682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2023
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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Administrator will hire more staff and generate a new atcivities calendar with impute from residents in care.
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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) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
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:
08/02/2023
UNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:OPERATIONS DIRECTOR DIMPLE KAMDARTIME COMPLETED:
04:00 PM
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
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) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BROOKDALE SANTA MONICA GARDENS
FACILITY NUMBER: 197606682
VISIT DATE: 08/02/2023
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) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5