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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609336
Report Date: 10/05/2021
Date Signed: 07/06/2022 01:50:29 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
01/12/2021 and conducted by Evaluator Troy Agard
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210112113911
FACILITY NAME:WELBROOK SENIOR LIVING SANTA MONICAFACILITY NUMBER:
197609336
ADMINISTRATOR:COLE, DAVIDFACILITY TYPE:
740
ADDRESS:1450 17TH STREETTELEPHONE:
(424) 282-3002
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY:50CENSUS: 28DATE:
10/05/2021
UNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:David Cole TIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Unlicensed staff administered insulin to resident with dementia.
Staff did not assist resident with administration of oxygen.
Staffing levels are not adequate to meet the needs of the residents.
Facility did not notify responsible parties of changes in residents health.
Residents' hygiene care needs are not being met.
INVESTIGATION FINDINGS:
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***This is an amendment of the investigation report delivered on 10/05/2021. ***
Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation to deliver findings for the allegations listed above. LPA met with Administrator, Kristin Beck and explained the purpose of today’s visit.

The investigation consisted of the following: On 01/20/2021 an initial 10-day visit was conducted by LPA Agard virtually due to the situation surrounded Coronavirus (Covid 19), and to implement mitigation measures. The following records were requested from then Administrator, Vladimir Kaplun: 1) a copy of the staff roster, 2) a copy of the resident roster with their responsible party, 3) a copy of the Medication Administration Records for all residents for December 2020.

On 08/24/2021 an in-person visit was conducted to interview staff and residents. Due to the need to analyze additional documents, the complaint needed further investigation.
Cont on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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 3
Control Number 11-AS-20210112113911
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: WELBROOK SENIOR LIVING SANTA MONICA
FACILITY NUMBER: 197609336
VISIT DATE: 10/05/2021
NARRATIVE
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On 07/06/2022 findings were delivered.

Regarding the allegation: Unlicensed staff administered insulin to resident with dementia. It’s being alleged “the former Administrator administered long acting insulin to a resident with dementia.” The investigation revealed the following: 6 out of the 7 staff interviewed, denied, or could not confirm the allegation to be true. S1 states, “I don’t know them to act in that role. S2-4 all state not being aware. S5, while unable to confirm or deny the allegation, states that S7 never came around. S6 states the allegation did happen but does not have any witnesses or evidence that could corroborate the allegation. All residents interviewed (R3-5) were unable to confirm or deny the allegation due to their cognitive abilities. R1 and R2 were unavailable for an interview. W1 states hearing a rumor that coincides with the allegation.

Regarding the allegation: Staff did not assist resident with administration of oxygen. It’s being alleged that a resident did not receive oxygen that was requested on their behalf. The investigation revealed the following: 5 out of the 7 staff interviewed, denied or could not confirm the allegation to be true. S1 states not being sure if R2 was in need of oxygen due to their absence from the facility. S2 states it wasn’t something the facility provided regularly, and it might have been a service provided while on hospice care. S3 states being unaware. S4-5 were both unable to confirm. All residents interviewed (R3-5) were unable to confirm or deny the allegation due to their cognitive abilities. R1 and R2 were unavailable for an interview. W1 was not able to confirm or deny the allegation.

Regarding the allegation: Staffing levels are not adequate to meet the needs of the residents. It’s being alleged that due to low staffing levels residents were unkempt and dirty. The investigation revealed the following: 5 out of the 7 staff interviewed, denied or could not confirm the allegation to be true. S1 states they are unable to speak on the previous time frame but noted that “adequate staff is debatable and is not clearly spelled out in title 22. S2 & S3 states the facility “could always use more help but understands there’s a “shortage everywhere and that they do their best.” S4, did not confirm the allegation but states they didn’t have enough supplies at the time to meet the needs of residents. S5 was unable to give a concise response. S6 states, while there were temp agency staff it wasn’t sufficient, and residents were being left dirty. S7 denies allegation, citing the fact that the facility was working with a “staffing agency” and while they were low on regular staff, they utilized an agency to help them with their staffing crisis. R3 and 4 state their needs are being met. R1 and R2 were unavailable for an interview. W1 states, there weren’t enough qualified staff. “there were temps that did not know the clients. Some really good staff left due to poor management of S7 or were lied on and let go.”

Continued on 9099C

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20210112113911
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: WELBROOK SENIOR LIVING SANTA MONICA
FACILITY NUMBER: 197609336
VISIT DATE: 10/05/2021
NARRATIVE
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Regarding the allegation: Facility did not notify responsible parties of changes in residents health. It’s being alleged that the families of residents in care were not able to reach the facility to get an update. The investigation revealed the following: 5 out of the 7 people interviewed, denied or could not confirm the allegation to be true. S1 states the facility has been “historically” good at communicating with the families. S2 states being unaware of the breakdown in communication. Citing, when something happens the families are the first to know. S2 & S3 also states the communication of a change in condition is usually reported to the families by the Director of nursing (not the Executive Director). While S4 states hearing rumors that the families were not being communicated with they could not confirm the allegation to be true. S5 was unable to give a concise response. S6 states having several missed communication efforts from the family regarding updates on their relatives. Citing, “I had 56 missed calls.” S7 states that families were communicated with daily due to being in the midst of the corona virus pandemic. All residents interviewed (R3-5) were unable to confirm or deny the allegation due to their cognitive abilities. R1 and R2 were unavailable for an interview. W1 describes the communication with S7 as poor and horrendous. “I never heard from them. The communication was zero.” W1 states that another facility staff “stepped up” and communicated with them.
Regarding the allegation: Residents' hygiene care needs are not being met. It’s being alleged that residents in care are not having their hygiene needs addressed. The investigation revealed the following: 5 out of the 7 people interviewed denied or could not confirm the allegation to be true. S1 states not seeing any issues with staff not wanting to assist residents with their hygiene needs. S2 denied the allegations, citing: “It’s such a small facility, I’m not sure why someone would say that.” S3 states the resident’s hygiene needs were still being met. S4 states the facility was low on hygiene supplies during covid. S5 was unable to give a concise response. S6 states facility staff was not adequate to meet the needs of the residents. S7 denies the allegation, citing the resident’s needs were being met it was just a “tough time” during covid. R3 and 4 state their needs are being met. R1, 2 and 5 were unable to answer the question. W1 states not having proof but suspects the allegation to be true.

During a review of records, R1 is noted to be insulin dependent. The medication administration records (MAR) from November, December 2020 and January 2021 do not indicate S7 giving insulin. LPA observed a prescription for R2 dated 12/19/2020 for administration of oxygen. A review of the MAR for R2 in December 2020 does not reflect this order. A review of a progress note for R1 shows resident was hospitalized 4 days later on 12/23/2020 for issues with their oxygen levels. LPA was not able to verify if there was a staffing shortage due to the unavailability of the schedule from December 2020.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted, and a copy of the report was given to Administrator, Kristin Beck.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3