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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609336
Report Date: 04/03/2025
Date Signed: 04/03/2025 12:35:08 PM

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
01/13/2025 and conducted by Evaluator Deborah Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250113093823
FACILITY NAME:WELBROOK SENIOR LIVING SANTA MONICAFACILITY NUMBER:
197609336
ADMINISTRATOR:COLE, CATALINAFACILITY TYPE:
740
ADDRESS:1450 17TH STREETTELEPHONE:
(424) 282-3002
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY:50CENSUS: 47DATE:
04/03/2025
UNANNOUNCEDTIME BEGAN:
08:06 AM
MET WITH:David ColeTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Resident sustained a serious injury while in care.
Resident left facility unsupervised.
INVESTIGATION FINDINGS:
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On April 3, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted a subsequent complaint visit to continue investigation and to deliver findings regarding the above allegations. LPA Lee met with David Cole Executive Director and explained the reason for the visit.

The investigation consisted of the following:
On January 17, 2025, during initial 10-day visit, LPA Lee and David Cole toured the facility inside and out and tested the upstairs alarm system and delayed egress which was operational. LPA requested and reviewed, staff roster (dated 9/21/24), resident's roster (dated 12/30/24), Incident Reports (dated 12/19/23 and 2/2/24) Elopement Procedure, Preplacement Appraisal Information for R1 (dated 12/30/22), Physician's Report for Residential Care for the Elderly (RCFE) dated 12/29/22. LPA reviewed Admission Agreement (date signed 1/4/23). LPA Lee interviewed Executive Director/Administrator (A1), 7 residents (R2-R8), and 7 staff (S1- S7).
Page 1 of 4
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
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 7
Control Number 11-AS-20250113093823
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: WELBROOK SENIOR LIVING SANTA MONICA
FACILITY NUMBER: 197609336
VISIT DATE: 04/03/2025
NARRATIVE
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On April 3, 2025, during subsequent visit, LPA Lee obtained a copy of elopement procedure training and sign in sheet. The training was conducted March 17-28, 2025.

During the investigation, LPA conducted 5 additional staff interviews (S8-S12) via telephone and/or obtained written statements due to their shift schedule and availability at the time of LPA’s visit.

The investigation revealed the following:

Resident sustained a serious injury while in care

The detail of the complaint alleges that on February 2, 2024 R1 sustained a fractured hip while eloping from facility. On 1/17/2025 between 8:30am and 9:40am, LPA interviewed Administrator David Cole (A1) who did not deny the allegation and informed LPA that he was aware of the incident and completed an Unusual Incident Report (UIR) when it occurred. A1 stated that all exit doors are delayed egress and equipped with a secondary alarm. Despite the alarms on the exit door, R1 was able to get out of the facility and subsequently found in the rear of building. On 01/17/2025, LPA reviewed ambulance transport document, which revealed that on 2/2/24 at 10:00pm R1 was seen by a passerby laying on ground in alleyway near facility. 911 was called, R1 reportedly complained of hip pain. Emergency services transported R1 to Ronald Reagan Medical Center. The review of R1's Emergency Department to Hospital admission/discharge documentation (MR #6530489) dated 2/2/24 revealed that R1 arrived via ambulance transport to ER and was subsequently admitted to hospital. R1’s diagnosis was Intertrochanteric Fracture, Osteoporotic Hip Fracture. R1 was treated and discharged on 2/10/2024.

Page 2 of 4

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20250113093823
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: WELBROOK SENIOR LIVING SANTA MONICA
FACILITY NUMBER: 197609336
VISIT DATE: 04/03/2025
NARRATIVE
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Based on the information gathered, there is sufficient evidence to support the stated allegation.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Resident left facility unsupervised

The detail of the complaint alleges that on February 2, 2024 Welbrook Senior Living staff was not aware that R1 had left the facility until they were notified by the paramedics who responded to the call of a woman lying in an alleyway behind the facility. On 1/17/2025 between 8:30am and 9:40am, LPA interviewed Administrator David Cole (A1) who confirmed the allegation. On 0/17/2025, LPA interviewed 7 staff regarding the allegation and of those interviewed, 7 out of 7 stated that R1 did not elope on their shift but they were aware of the incident. 7 out of 7 stated that they are all training on the alarm system and the elopement protocol. Of the 5 additional staff interviewed, 4 out of 5 were on shift during R1’s elopement; 4 out of 5 stated they did not hear the alarm as they were downstairs preparing for a shift transition. On 4/3/25 during subsequent visit, A1 confirmed that the alarm can not be heard on first floor of the facility. Additionally, 4 out of 5 indicated that they are trained on the alarm system and the elopement protocol. On 1/17/25 LPA obtained/reviewed Unusual Incident Report (UIR) dated 2/3/24 explaining the incident which corroborated the allegation.

Page 3 of 4

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20250113093823
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: WELBROOK SENIOR LIVING SANTA MONICA
FACILITY NUMBER: 197609336
VISIT DATE: 04/03/2025
NARRATIVE
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Based on the information gathered, there is sufficient evidence to support the stated allegation.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations, Title 22, Division 6 and Chapter 8 article 12 are being cited on the attached LIC 9099D.

Exit interview conducted and copy of report given to David Cole, Executive Director.

Page 4 of 4

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20250113093823
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: WELBROOK SENIOR LIVING SANTA MONICA
FACILITY NUMBER: 197609336
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2025
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following… (2) To be accorded safe, healthful and comfortable accommodations...
This requirement was not met as evidenced by:
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The administrator to complete and submit a written plan to LPA ensuring the safety of all residents via email to Deborah.Lee@dss.ca.gov by POC due date 4/10/25.
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Based on interviews and records review. Licensee did not ensure the safety of (R1) who wandered out of the facility, unsupervised by staff. R1 Sustained a serious injury during elopement from facility on 2/2/24.. This violation poses a potential health and safety risk to clients in care.
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Type B
04/10/2025
Section Cited
CCR
87705(e)(7)
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87705 (e)(7) Care of Persons with Dementia
(e) Licensees that use delayed egress devices on exterior doors... shall meet the following requirements…(7) Delayed egress devices shall not substitute for trained staff...to meet the care and supervision needs of all residents, including staff needed to escort residents who need supervision to leave the facility.
This requirement was not met as evidenced by:
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Administrator agreed to ensure that there will always be staff on 2nd floor including during shift transition periods. The administrator to forward policy to LPA via email by POC due date 4/10/25.
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Based on interviews, and record review staff were not on 2nd floor where R1 eloped from at time of incident and did not hear the alarm.This violation poses a potential health and safety risk to clients 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.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
01/13/2025 and conducted by Evaluator Deborah Lee
COMPLAINT CONTROL NUMBER: 11-AS-20250113093823

FACILITY NAME:WELBROOK SENIOR LIVING SANTA MONICAFACILITY NUMBER:
197609336
ADMINISTRATOR:COLE, CATALINAFACILITY TYPE:
740
ADDRESS:1450 17TH STREETTELEPHONE:
(424) 282-3002
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY:50CENSUS: 47DATE:
04/03/2025
UNANNOUNCEDTIME BEGAN:
08:06 AM
MET WITH:David ColeTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to report resident injury to responsible party.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On April 3, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted a subsequent complaint visit to continue investigation and to deliver findings regarding the above allegation. LPA Lee met with David Cole Executive Director and explained the reason for the visit.

The investigation consisted of the following:
On January 17, 2025, during initial 10-day visit, LPA Lee and David Cole toured the facility inside and out and tested the upstairs alarm system and delayed egress which was operational. LPA requested and reviewed, staff roster (dated 9/21/24), resident's roster (dated 12/30/24), Incident Reports (dated 12/19/23 and 2/2/24) Elopement Procedure, Preplacement Appraisal Information for R1 (dated 12/30/22), Physician's Report for Residential Care for the Elderly (RCFE) dated 12/29/22. LPA reviewed Admission Agreement (date signed 1/4/23). LPA Lee interviewed Executive Director/Administrator (A1), 7 residents (R2-R8), and 7 staff (S1- S7).

page 1 of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20250113093823
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: WELBROOK SENIOR LIVING SANTA MONICA
FACILITY NUMBER: 197609336
VISIT DATE: 04/03/2025
NARRATIVE
1
2
3
4
5
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Staff failed to report resident injury to responsible party

On 1/17/2025, LPA obtained/reviewed the Unusual Incident Report(UIR) dated 2/3/24 sent by facility. The report indicated that the responsible party was contacted.

On 1/17/2025 staff #6 indicated that she contacted responsible party to inform him of the incident.

Based on the information gathered, there is insufficient evidence to support the stated allegation

Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation are UNSUBSTANTIATED

No deficiencies were cited for the above allegations. Exit interview was conducted. A copy of this report was provided to David Cole, Executive Director.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7