Allegation #1: Staff did not adequately address resident's fall risk.

Resident #1 (R1) was admitted to Welbrook Santa Monica on June 30, 2023, in accordance with the facility’s Admission Agreement (dated 06/30/23). (R1) voluntarily terminated their residency on February 21, 2026, at which time personal belongings were removed from the premises. From November 19 to November 23, 2025, (R1) received medical attention at Ronald Reagan UCLA Medical Center for a visual injury, necessitating transportation to the hospital for appropriate treatment.

On February 5, 2026, and May 7, 2026, between 11:34 AM and 01:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Six (6) out of the six (6) staff members could not validate both claims. The initial assessments conducted by (S1-S2) indicated that (R1) did not have a prior history of falls from (R1’s) primary care physician. The Physician’s Report LIC 602A (dated 06/14/23) did not identify (R1) as a fall risk. However, the facility’s Senior Living Functional Assessment (ISP) (dated 05/07/26) noted that (R1) had experienced a few falls and that a fall prevention plan was implemented. It was confirmed by (S1-S2) that, despite initial assessment noting a history of falls, (R1) did not experience any falls during care at the facility. (S1-S6) confirmed that before (R1) being admitted to Welbrook Senior Living, (R1) had a medical assessment that revealed visual impairment related to glaucoma.

On November 19, 2025, an incident involving (R1) was reported as having an unwitnessed fall. At 4:50 AM, a staff member discovered (R1) sitting on the bed, holding (R1’s) eye. Upon examination, a skin tear or cut near (R1’s) eye was identified. The area was promptly cleaned, and emergency services were called; (R1) and were subsequently transported to the hospital. (S1) confirmed that a thorough inspection of (R1’s) room revealed no blood on the floor or any evidence of a fall. It appears likely that (R1) unintentionally rolled over in bed and hit (R1’s) face against the sharp corner of the night stand, resulting in the eye injury.

(Evaluation Report continues LIC 9099-C)

On May 7, 2026, between 11:16 AM and 12:00 PM, the Department interviewed resident members identified as Resident #2 through Resident #6 (R2-R6). Five (5) out of five (5) residents could not support these claims. (R2-R6) confirmed that they have not experienced any falls and have not sustained injuries from falls. They expressed appreciation for the staff, noting that they are watchful in monitoring all residents and will escort them to prevent falls while under their care.

The Department was unable to conduct an interview with Resident #1 (R1) due to (R1's) unavailability.

Furthermore, the Department was unable to reach Witness #1 (W1) as the calls went unanswered.

A review of (R1’s) Physician’s Report LIC 602A (dated 06/14/23), Preplacement Appraisal Information LIC 603 (dated 06/30/23), Senior Living Functional Assessment (ISP) (dated 06/29/23), Fall Risk Assessment (dated 11/24/25) revealed (R1) was assessed before admittance at the facility with a visual impairment and had a fall plan in place. Further review of UCL A Health Medical Records (dated 11/23/25), Physician’s Office Visit (dated 12/05/25), Unusual Incident Report LIC 624 (dated 11/19/25), and Fall Risk Assessment (dated 11/24/25) revealed there is no proof to suggest that an impact from a fall and eye injury resulted in blindness. Further review of Preplacement Appraisal Information LIC 603 (dated 06/30/23) revealed visual impairment related to glaucoma.

On February 5, 2026, between 8:12 AM and 12:47 PM, the Department inspected (R1's) room. During the inspection, it was noted that the room contained minimal furnishings, including a mattress and box spring without a bed frame, a nightstand, a dresser, a club chair, an over-bed table, and a television. The nightstands were equipped with furniture corner guards for safety. Additionally, the shower was fitted with grab bars, a shower seat, non-skid flooring, and an adjustable commode chair with handles.

Allegation #3: Staff left resident unsupervised for an extended period of time.

It is alleged that staff member Resident #1 (R1) was left unsupervised for an extended period. On January 24, 2026, it was reported that R1 was found on the floor in liquid waste, which had allegedly occurred the previous day. Concerns have been raised about staffing levels. No further details regarding this matter were provided.

On February 5, 2026, and May 7, 2026, between 11:34 AM and 01:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Six (6) out of the six (6) staff members could not support this claim. (S1) expressed on January 22, 2026, (R1) has shown increasing agitation towards staff over the past few days, prompting them to notify the family representative Witness #1 (W1) about the significant change in (R1’s) condition. Witness #1 (W1) was urged to consider taking (R1) to the hospital. While waiting, staff closely monitored (R1) to ensure safety, but (R1) continued to display aggressive behavior, including making a mess of (R1’s) bodily fluids. When (W1) arrived and found it challenging to manage (R1’s) behavior, the facility called 9-1-1; however, ultimately (W1) declined EMS assistance and chose to transport (R1) to the hospital. (W1) also attempted to clean (R1) before the hospital visit but had limited success. (S1) since the hospitalization, reported (R1) never returned back to the facility.

(S1-S5) confirmed that there is no staffing shortage and that adequate staffing is maintained for all shifts. For the morning shift, which is from 6:30 AM to 3:00 PM, the regular staffing consists of eight care staff members, two licensed vocational nurses, one medication technician, and two activity directors. The evening shift, from 2:30 PM to 11:00 PM, includes seven care staff members, one licensed vocational nurse, and one medication technician. The night shift, from 10:30 PM to 7:00 AM, has five care staff members. (S1-S2) reported that the facility handles call-outs by offering extra hours to existing staff to cover shifts. In the event of a staffing crisis, the facility employs personnel from 1Heart Caregivers Services. (S1-S5) stated that (R1) never experienced staff shortages. (R1) was monitored every two hours or as needed.

Additionally, (S2) reported that Resident #1 (R1) received assistance from a private care staff member provided by Santa Monica UCLA following (R1's) hospitalization in November 2025. This assistance lasted for 30 days. (S1-S2) also offered (R1) a stand-by care staff member to monitor and escort (R1) at no extra charge, even though (R1) was medically assessed as not needing one-on-one care after hospitalization.

(Evaluation Report continues LIC 9099-C)

The Department was unable to conduct an interview with Resident #1 (R1) due to (R1’s) unavailability.

Furthermore, the Department was unable to reach Witness #1 (W1) as the calls went unanswered.

The Department reviewed the facility’s Personnel Report LIC 500 (dated 12/23/25 and 04/08/26) confirmed the staffing numbers of personnel for each shift as stated by (S1-S5). Further review of Annual and Continuing Education Training materials and Relias Training verified the mandatory staff training implementation by the facility. A review of Unusual Incident Report LIC 624 (dated 11/19/25 and 01/26/25).

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated.

An exit interview was conducted with David Cole, and copies of the reports were provided.