198204758-6-9-2021-11-AS-EMAZ-C57U2N-20210723151209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204758
Report Date: 06/09/2021
Date Signed: 06/09/2021 03:52:38 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
06/03/2021 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20210603152736

FACILITY NAME:	BROOKDALE OCEAN HOUSE		FACILITY NUMBER:	198204758
ADMINISTRATOR:	PARK, THOMAS		FACILITY TYPE:	740
ADDRESS:	2107 OCEAN AVE		TELEPHONE:	(310) 399-3227
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90405
CAPACITY:	150	CENSUS: 83	DATE:	06/09/2021
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Tom Rekowski-Executive DIrector		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility did not release resident's records to resident respresentative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced complaint investigation at above facility. LPA arrived at facility at 8:00 am and was greeted by staff Adam Synchoff. LPA explained the purposed of the visit was to investigate the allegation listed above and was granted access to the facility.

The investigation consisted of the following:

On 6/9/2021 LPA Cifuentes conducted a tour of facility grounds. Tour consisted of lounge area, kitchen, dining room, front lobby, several resident rooms and bathrooms. LPA interviewed Executive Director Tom Rekowski, staff 1-staff 4 as well as resident 1-resident 7. LPA requested and received the following documents: staff and client rosters, copy of records request, email verifying records request completed.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

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-20210603152736

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: BROOKDALE OCEAN HOUSE	FACILITY NUMBER: 198204758
	VISIT DATE: 06/09/2021

NARRATIVE

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Regarding the allegation: Facility did not release resident's records to resident representative.

The investigation revealed the following:

On 6/9/20211 at 9am LPA Cifuentes spoke with Executive Director Tom Rekowski. Mr. Rekowski told LPA that facility had recently received a records request from a law firm on 5/25/2021. The request was accompanied by paperwork confirming the law firm as an authorized legal representative. Mr. Rekowski called the law firm on 5/26/2021 as indicated on the request and stated they would need more than a few days to fulfil the request. He then directed them to the legal clerk who would be forwarding them the files. Mr. Rekowski stated he contacted the legal department to make them aware of the request, then emailed them the first part of the file on 5/26/2021. He sent the rest of the files several days later, on 6/7/2021, once they had been pulled from the archive.

ON 6/9/2021 from 10-11am LPA reviewed records received from facility. Residents admissions agreement section H states that residents, “Have the right to review and access your health care records in accordance with the requirements of applicable law.”

On 6/9/2021 from 12-1pm LPA Cifuentes interviewed resident 1 -resident 7. LPA asked residents if they or their authorized representative had ever requested to see their facility record. Six out of seven residents stated they had not requested their facility records. Resident 1 stated they had requested to be given a copy of a file in their medical record and received it within minutes of their request.

continued on 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20210603152736

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: BROOKDALE OCEAN HOUSE	FACILITY NUMBER: 198204758
	VISIT DATE: 06/09/2021

NARRATIVE

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On 6/9/2021 LPA Cifuentes interviewed staff 1-3. LPA asked staff if they had received any records request from residents or their authorized representatives. Two out of three staff stated they had not. Staff 1 stated they had received a records request from a family member, but as that family member was not on file as POA, they sent the requested file the same day to the POA on file.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation 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 allegation is unsubstantiated.

An exit interview was conducted with Executive Director Tom Rekowski and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3