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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204069
Report Date: 11/18/2021
Date Signed: 11/18/2021 06:56:47 PM



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
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2021 and conducted by Evaluator Stephanie Cifuentes
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20211108102138
FACILITY NAME:SUNRISE ASSISTED LIVING OF SANTA MONICAFACILITY NUMBER:
198204069
ADMINISTRATOR:GOLIA, ALBERTOFACILITY TYPE:
740
ADDRESS:1312 15TH STTELEPHONE:
(310) 899-1976
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY:100CENSUS: 64DATE:
11/18/2021
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Aurora IsraelsonTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at above facility. LPA arrived at the facility and was greeted by receptionist. LPA explained purpose of visit was to deliver findings for the allegations listed above and was allowed entry to the facility to meet with Executive Director Matan Burnstyn.

The investigation consisted of the following: LPA toured the facility, reviewed facility files and interviewed Executive Director, residents 1-resident 6 (R1-R6) and staff 1-Staff 8 (S1-S8). Facility files were reviewed and copies of physician’s report and other documents in association with the allegations were received.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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 5
Control Number 11-AS-20211108102138
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
MONTERY PARK, CA 91754
FACILITY NAME: SUNRISE ASSISTED LIVING OF SANTA MONICA
FACILITY NUMBER: 198204069
VISIT DATE: 11/18/2021
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Illegal eviction
It is alleged that facility staff refused entry to facility upon return from hospital. LPA spoke to Administrator Matan Burstyn regarding allegation. Per Ms. Burstyn, no residents have been issued eviction notices but the spouse of R1 decided to move them from facility. There was no discussion with spouse of R1 about R1 returning to facility or a refusal of R1’s return. LPA spoke to S1 who stated that R1 had been hospitalized several times recently, and a request was made that R1 be evaluated at hospital during their last visit. LPA reviewed facility files which state that hospital called facility to say resident was ready to be released and when results of the evaluation were request, hospital stated it was not needed. Facility requested an evaluation be completed before readmission to the facility and hospital staff hung up. R1 and spouse returned to facility, collected some of R1’s items and left. LPA looked for an eviction notice in facility files and none were found. LPA spoke to residents 2 – residents 7 regarding allegation. Out of those interviewed, seven out of seven residents stated they have not been evicted nor do they know anyone who has been evicted. LPA Cifuentes interviewed staff 1-staff 8 regarding allegation. Of those staff interviewed, seven out of eight stated that residents had not been evicted.
Based on information gathered and service records reviewed, the Department did not find sufficient evidence to support the allegation mentioned above.

The Department’s investigation consisted of an inspection of the facility, observation, analysis of residents records and interviews conducted and found no evidence to support the allegations: “Illegal eviction” 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.

Exit interview conducted, and a copy of the report was given to Aurora Israelson.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2021 and conducted by Evaluator Stephanie Cifuentes
COMPLAINT CONTROL NUMBER: 11-AS-20211108102138

FACILITY NAME:SUNRISE ASSISTED LIVING OF SANTA MONICAFACILITY NUMBER:
198204069
ADMINISTRATOR:GOLIA, ALBERTOFACILITY TYPE:
740
ADDRESS:1312 15TH STTELEPHONE:
(310) 899-1976
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY:100CENSUS: 64DATE:
11/18/2021
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Aurora IsraelsonTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Facility nurse did not ensure memory care resident did not have access to ingestible objects
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at above facility. LPA arrived at the facility and was greeted by receptionist. LPA explained purpose of visit was to deliver findings for the allegations listed above and was allowed entry to the facility to meet with Executive Director Matan Burnstyn.

The investigation consisted of the following: LPA toured the facility, reviewed facility files and interviewed Executive Director, residents 1-resident 6 (R1-R6) and staff 1-Staff 8 (S1-S8). Facility files were reviewed and copies of physician’s report and other documents in association with the allegations were received.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20211108102138
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
MONTERY PARK, CA 91754
FACILITY NAME: SUNRISE ASSISTED LIVING OF SANTA MONICA
FACILITY NUMBER: 198204069
VISIT DATE: 11/18/2021
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility nurse did not ensure memory care resident did not have access to ingestible objects
It is alleged that Resident 1 (R1) ingested soap, rubber gloves and Halloween decorations while at the facility. LPA Cifuentes spoke with Executive Director Matan Burstyn regarding the allegation. Per Executive Director, facility found that resident had coffee grounds in her mouth. The facility was still observing the resident, to make sure they adjusted to the move in and were being assessed correctly. Once coffee was consumed the facility increased supervision. LPA reviewed records and per facility notes on 10/18/2021 Coffee Grounds and orange juice were found in residents’ mouth. On 11/6/2021 R1 was found with a bar of soap that had teeth marks and on 11/7/2021 gloves, masks and flower decoration where found and thought to have been ingested by resident. LPA spoke to residents regarding allegation and whether facility could accommodate their needs. Of the six questioned, all 6 stated their needs were being accommodated. LPA Cifuentes spoke with facility staff, of the eight questioned, seven stated that a resident had ingested objects. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

Based on information gathered, the department did find sufficient evidence to support allegation " Facility nurse did not ensure memory care resident did not have access to ingestible objects”

Based on interviews conducted and records reviewed 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 and Chapter 8 are being cited on the attached LIC 9099D.



An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to Matan Burnstyn.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20211108102138
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
MONTERY PARK, CA 91754

FACILITY NAME: SUNRISE ASSISTED LIVING OF SANTA MONICA
FACILITY NUMBER: 198204069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2021
Section Cited
CCR
87468.2(a)(8)
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To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
This requirment was not met as evidenced by:
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Adminstrator will conduct a staff in service training on Dementia and provide sign in sheet to CCLD via fax or email by POC due dte



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Through observation and interview, LPA Cifuented noted that R1 ingested items on 10/18/2021, 11/6/2021 and 11/7/2021. This is a potential health and safety violation to the residents 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: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5