198204069-3-12-2022-11-AS-MVAO-CGNS2H-20220725132931

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204069
Report Date: 03/09/2022
Date Signed: 03/12/2022 12:31:16 AM

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
03/03/2022 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20220303115809

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: 71	DATE:	03/09/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Matan Burstyn and Aurora Israelson		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility failed to reassess resident.
Facility failed to notify POA of resident's change of condition.
Facility increased the rate without proper notice.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Wednesday, March 09, 2022. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is not cleared of COVID-19 infection. LPA Bunker met with Executive Director Matan Burstyn and Business Office Coordinator Aurora Israelson. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: LPA Bunker interviewed staff 1-2 (S1-S2) and residents 2-7 (R2-R7). LPA Bunker asked questions relevant to the nature of the complaint. Staff stated resident was reassessed, her Power of Attorney (POA) was notified of the resident's change of condition, the facility increased the rate with proper notice. LPA Bunker requested copies of resident's admission agreement, physician's reports, medical assessment, consent for medical treatment, needs and service plan, staff personal record, resident's records, progress notices, itemization for the account of R1, letters, and emails correspondence regarding R1 billing with POA. See continued LIC812-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

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 3

Control Number 11-AS-20220303115809

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: SUNRISE ASSISTED LIVING OF SANTA MONICA	FACILITY NUMBER: 198204069
	VISIT DATE: 03/09/2022

NARRATIVE

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Continued LIC9099-C page 2

Allegation: Facility failed to reassess resident. Interviews were conducted with staff 1-2 (S1-S2) Staff stated that they never failed to reassess residents. Staff stated all documentation and communication is noted. Residents 2-7 (R2-7) stated If a resident needs reassessment they are made aware and their family members, the responsible party are notified of any changes.

Allegation: The facility failed to notify the POA of the resident's change of condition. Staff stated resident POA was notified of the change in condition. All documentation and communication were noted. Residents stated if there is a change in their conditions their physicians, family members, and responsible party are notified immediately.

Allegation: The facility increased the rate without proper notice. Staff stated resident's POA was given proper notification of the rate increase. All documentation and communication are noted. Residents stated if there is a rate increase they receive proper notification and their, family members and responsible party is notified immediately.

Investigation revealed the following: Staff 1-2 (1-2) provided LPA Bunker with copies of R1 admission agreement, Individual needs and service plan, service level fees, physician's reports, telephone calls with R1's POA on 09/02/2021, 09/21/2021, 12/24/2021, 12/30/2021, and 02/06/2022 regarding change of care level. Staff stated POA agreed on moving residents to REM and agreed with the level of care via telephone conversation. Staff stated Sunrise Assisted Living of Santa Monica mailed letters to POA on 08/28/2021, 10/25/2021, 12/25/2021, and 02/08/2022 regarding the rate increase. R1's progress notes dated 11/19/2021 - 03/06/2022 were documented in R1 change in condition. Staff provided proof of all documentation and communications regarding the allegations with R1's POA. R2-R7 interviewed stated that they had no issues, problems, or concerns and was happy with the staff, the care, and supervision and their daily needs are being met. The facility staff stated the allegations are false and denied all allegations.

See continued LIC9099 page 3

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20220303115809

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: SUNRISE ASSISTED LIVING OF SANTA MONICA	FACILITY NUMBER: 198204069
	VISIT DATE: 03/09/2022

NARRATIVE

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Continued LIC9099 page 3

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation 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 is deemed unsubstantiated.

There were no deficiencies cited.

Exit interview conducted.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

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