198204069-5-17-2024-11-AS-SCIS-D5HMVZ-20240522095732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204069
Report Date: 12/29/2022
Date Signed: 05/17/2024 12:03:57 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
12/27/2021 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211227092512

FACILITY NAME:	SUNRISE ASSISTED LIVING OF SANTA MONICA		FACILITY NUMBER:	198204069
ADMINISTRATOR:	GOLIA, ALBERTO		FACILITY TYPE:	740
ADDRESS:	1312 15TH ST		TELEPHONE:	(310) 899-1976
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90404
CAPACITY:	100	CENSUS: 60	DATE:	12/29/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Henry Reyes - Business Office Manager		TIME COMPLETED:	03:58 PM

ALLEGATION(S):

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Facility charging resident for services that are not being performed

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

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 9

Control Number 11-AS-20211227092512

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: SUNRISE ASSISTED LIVING OF SANTA MONICA	FACILITY NUMBER: 198204069
	VISIT DATE: 12/29/2022

NARRATIVE

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This document has been amended to clarify findings, it does not change the findings delivered on 12/29/2022.
The investigation consisted of the following: On 12/28/2021 LPA Stephanie Cifuentes toured the inside and outside grounds of the facility to conduct a heal and safety check and requested copies of facility documents. On 12/28/2021, 1/25/2022 and 4/13/2022 LPA Cifuentes conducted interviews with facility staff and residents. During the course of the investigation LPA requested and received copies of the following: client roster, staff roster; ID and emergency information, physicians’ reports, admissions agreement, resident appraisal, monthly billing statements and all medical records to include any hospital records for Resident #1.

Allegation: Facility charging resident for services that are not being performed

It is alleged that facility is charging resident monthly for services that are not being completed by facility staff and not agreed upon by family. LPA Cifuentes reviewed facility records and found that the facility had three Service Change Approval forms on file for R1. Two of those, which were signed by facility staff, dated 7/11/2021 and 11/30/2021 were to increase residents care level to add assistance with their ADL’s. Per notes on the form dated 7/11/2021, family of R1 refused the change in services. Review of form dated 11/30/2021 show that a message was left for family but does not indicate an agreement to the change in services to resident. LPA Cifuentes received billing statements for R1 for the dates of July 2021 to May 2022. The statement dated 8/31/2021 shows charges for assisted living plus for the months of July, August and September. R1 was not previously being charged for any level of care. In the statement dated 9/31/2021 those charges were credited back. R1 was not charged for care in the initial bills sent for November, nor in the initial bill for December, but a second statement was sent for the month of December on December 10, 2021 with charges for a higher level of care for the months of December and January. These charges continued on the billing statement issued for January 2022 and rolled over to future billing statements even when the resident had left the facility. Interviews with staff 1-7 (S1-S7) indicate that facility residents are not paying for services they are not receiving, with some staff elaborating that R1 would deny all offers of assistance with their ADL’s. LPA spoke with residents 1-resident 8 (R1-R8) regarding allegation. R1 was unavailable and one other resident refused to answer. Out of those interviewed 1 out of the 8 stated they believed they were over charged.
Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title 22 Division 6 Chapter 8 is being cited (please see LIC9099D.)
Exit interview was conducted with Business Office Manager, Henry Reyes. A hard copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 11-AS-20211227092512

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: SUNRISE ASSISTED LIVING OF SANTA MONICA	FACILITY NUMBER: 198204069
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/12/2023 Section Cited CCR 87507(3)(B)(2)	1 2 3 4 5 6 7	87507(3)(B)(2) Admissions Agreements A separate charge for an item or service may be assessed only if that charge is included in and authorized by the admissions agreement. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will review billing statements for resident, remove any charges for care, and issue any refunds if necessary, to POA for R1. A copy of updated billing statement(s) will be submitted to CCLD via fax by POC due date.
	8 9 10 11 12 13 14	Based on records review, it was noted that R1 was charged for services that were not approved by POA. This poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 9

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
12/27/2021 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211227092512

FACILITY NAME:	SUNRISE ASSISTED LIVING OF SANTA MONICA		FACILITY NUMBER:	198204069
ADMINISTRATOR:	GOLIA, ALBERTO		FACILITY TYPE:	740
ADDRESS:	1312 15TH ST		TELEPHONE:	(310) 899-1976
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90404
CAPACITY:	100	CENSUS: 60	DATE:	12/29/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Kaylee Garcia - Business Office Coordinator		TIME COMPLETED:	03:58 PM

ALLEGATION(S):

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Facility failed to reassess resident.
Resident was injured while in care
Staff are harassing resident.
Facility is not providing resident with 3 meals a day.

INVESTIGATION FINDINGS:

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This document has been amended to clarify findings, it does not change the findings delivered on 12/29/2022.

Licensing Program Analyst (LPA) Mario Leon conducted an unannounced subsequent complaint visit to facility at 1:40PM. LPA spoke to administrator Kaylee Garcia prior to entering the facility to conduct a risk assessment. Julie Stone informed the LPA that the facility has no Covid-19 cases nor do any of the residents or staff have symptoms. LPA arrived at facility and was met by Julie Stone and explained the purpose of the visit is to deliver findings on the allegations listed above and was allowed entry to the facility

The investigation consisted of the following: On 12/28/2021 LPA Stephanie Cifuentes toured the inside and outside grounds of the facility to conduct a health and safety check and requested copies of facility documents. On 12/28/2021, 1/25/2022 and 4/13/2022 LPA Cifuentes conducted interviews with facility staff and residents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 9

Control Number 11-AS-20211227092512

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: SUNRISE ASSISTED LIVING OF SANTA MONICA	FACILITY NUMBER: 198204069
	VISIT DATE: 12/29/2022

NARRATIVE

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This document has been amended to clarify findings, it does not change the findings delivered on 12/29/2022.
During the course of the investigation LPA requested and received copies of the following: client roster, staff roster; ID and emergency information, physicians’ reports, admissions agreement, resident appraisal, monthly billing statements and all medical records to include any hospital records for Resident #1.

Investigation revealed the following:

Allegation: Facility failed to reassess resident.
It is alleged that facility did not complete a reassessment on R1. LPA spoke with facility staff S1 and S2, who both stated resident reassessments are based on facilities general assessment form, LIC 602 Physicians Assessment for Residential Care Facilities for the Elderly and observation of the client while in care of the facility. LPA Cifuentes reviewed facility records which had several physicians’ assessments on file. Physicians’ Report dated 7/9/2018 shows R1 needed no assistance with ADL’s when they entered the facility. Physicians report for 8/3/2021 shows that R1’s condition had changed, and they needed supervision and assistance for safety. Physician’s report dated 11/2/2021 changed slightly as well, noting a further increase in assistance needed. LPA Cifuentes found a reassessment for R1 with an effective date of 11/28/2021 which, per the documentation, was completed due to a change in condition. LPA received a copy of an email dated 11/28/2022 in which family of R1 mentions that facility staff asked R1 and family questions regarding R1’s ability to handle their own ADL’s on two separate occasions. LPA Cifuentes interviewed W1, Primary Care Physician of R1 on 1/14/2022. W1 stated they believed resident needed a higher level of care and that they did in fact fill out most of the LIC 602 Physicians Report provided by facility, they only had a doubt about one page, which they believed was not their handwriting. They stated they were unsure if it was completed by their staff or the facility. They did not disagree with what was written on the document. LPA Cifuentes spoke with staff 1-6 (S1-S6), and of those interviewed, 5 answered that residents are reassessed every 6 months or with a change in condition. LPA Cifuentes spoke with residents 2-8 (R2-R8). R1 was unavailable for interview and another resident declined to answer. Of those 6 who did answer, two of those residents were able to state they were aware of reassessments occurring, another adding that the facility staff had noticed a difference in their gate.

The Department finds no evidence to support the allegation mentioned after observing, interviewing, reviewing, and analyzing the records. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated.

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 9

Control Number 11-AS-20211227092512

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: SUNRISE ASSISTED LIVING OF SANTA MONICA	FACILITY NUMBER: 198204069
	VISIT DATE: 12/29/2022

NARRATIVE

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This document has been amended to clarify findings, it does not change the findings delivered on 12/29/2022.
Allegation: Resident was injured while in care
It is alleged that R1 fell while in the care of the facility. R1 was admitted to facility on 7/24/2018. According to R1’s physicians report upon admission to facility, R1 was ambulatory, able to handle activities of daily living on own and only needed assistance with medication management.
LPA Cifuentes reviewed hospital records for R1, which show R1 was admitted to Providence Saint John’s Health Center on 7/14/2019 with a diagnosis of pleurodynia, closed fracture of multiple ribs on left side, and compression fracture of thoracic vertebra. Per doctors’ notes, caretaker, who was at R1’s bedside, stated R1 suffered a witnessed fall two days prior when R1 was attempting to ambulate with walker. Caretaker told doctor R1 lost their balance and fell, striking left side and had been complaining of rib pain since that day.
LPA reviewed facility records and per records, on 7/11/2019 at 9:10pm, Resident was found on floor of suite, reporting to staff they had fallen. R1 was assisted to bed and a body check performed. A bruise was noted on chin to which an ice pack was applied. R1 complained of pain on left side but denied any PRN pain medication. Per notes, both doctor and family were notified, and facility would continue to monitor resident. An additional note, undated, states that at 9:15am resident pushed call button and told facility staff they had fallen and were experiencing left side pain. Wellness nurse was called to assess resident and POA was called, and staff shared concerns about increasing pain. Per facility records it was requested by POA that private caregiver accompany R1 to emergency room.
LPA spoke to Witness 2 (W2) private caregiver for R1, who stated they were not present for R1’s fall. They could state that R1 was careful with how they got up and how they moved, only time they might stumble is if not using walker, but they were being constantly observed for falls. W2 also added that R1 was doing ADLs on own and did not want help. LPA attempted to interview R1, but R1 was unavailable for interview.
LPA Cifuentes reviewed facility notes and found that R1 had at least 5 unobserved falls in their bedroom. During this time, resident was not receiving any assistance with ADLs from facility, per assessment completed on 11/28/2021, R1 had a fall care plan in place as they had several fall risk factors. Facility’s assessment states they would be observing and reporting any changes in gait and or balance as well as reminding R1 to rise and change positions slowly. Further interventions consisted of evaluation post fall and evaluating environment at time and location of fall, and attempt to identify factor that may have contributed such as uneven surfaces, bed not being in a low position, poor lighting, or glare, not wearing non-skid shoes, not using assistive devices, etc. and to report these to supervisor. Facility files also note that several attempts were made by facility to provide assistance with ADL’s to client, but they were refused by both family and resident. Resident continued to self-care independently after the incident and was accompanied by private caregiver.

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 11-AS-20211227092512

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: SUNRISE ASSISTED LIVING OF SANTA MONICA	FACILITY NUMBER: 198204069
	VISIT DATE: 12/29/2022

NARRATIVE

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This document has been amended to clarify findings, it does not change the findings delivered on 12/29/2022.
The Department finds no evidence to support the allegation mentioned after observing, interviewing, reviewing, and analyzing the records. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Staff are harassing resident.

It is alleged that facility staff continually entered R1’s room to harass resident. LPA reviewed facility files which show staff was concerned about R1, as several behavioral incidents had occurred. LPA interviewed S1, who stated facility staff were monitoring R1 due to behavioral incidents and belief resident needed a higher level of care. LPA also interviewed W2, who stated facility staff would check on resident to see if they needed assistance with ADLs. W1 did not define it as harassment. LPA Cifuentes spoke with staff 1-6 (S1-S6), and of those interviewed, all 6 stated they were not harassing facility residents. LPA Cifuentes attempted to interview R1, but they were not available. LPA Cifuentes interviewed residents 2-8 (R2-R8) and of those interviewed, 1 declined to answer but the other 6 stated they did not feel harassed by facility staff.

The Department finds no evidence to support the allegation mentioned after observing, interviewing, reviewing, and analyzing the records. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Facility is not providing resident with 3 meals a day.

It is alleged that facility staff did not provide resident with all their meals. LPA Cifuentes reviewed facility records. Per records, facility provides residents with three meals a day as well as snacks. LPA Cifuentes spoke to staff S1-S6. Of the staff interviewed, all six stated residents receive three meals a day plus snacks. In addition, LPA was told by S1 if a resident does not show up in the dining room, staff will go and look for them. If the resident is asleep, the meal is recooked, or the meal will be put in the fridge. For those who do not eat in the dining room meal trays are provided. Staff also added that if a resident is asleep during a mealtime, they will be awakened for the next meal, but if they still refuse to awake, items will be ordered from the kitchen and the food is left in their room. LPA Cifuentes attempted to interview R1, but they were not available. LPA Cifuentes interviewed residents 2-8 (R2-R8) and of those interviewed, 1 declined to answer but the other 6 stated they received three meals and snacks from the facility.

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 11-AS-20211227092512

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: SUNRISE ASSISTED LIVING OF SANTA MONICA	FACILITY NUMBER: 198204069
	VISIT DATE: 12/29/2022

NARRATIVE

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The Department finds no evidence to support the allegation mentioned after observing, interviewing, reviewing, and analyzing the records. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted with Business Office Manager, Henry Reyes, and a copy of the report was provided.

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC9099 (FAS) - (06/04)

Page: 9 of 9