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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204758
Report Date: 09/18/2023
Date Signed: 09/22/2023 12:12:43 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
10/28/2022 and conducted by Evaluator Pamela Bunker
COMPLAINT CONTROL NUMBER: 11-AS-20221028153233
FACILITY NAME:BROOKDALE OCEAN HOUSEFACILITY NUMBER:
198204758
ADMINISTRATOR:PARK, THOMASFACILITY TYPE:
740
ADDRESS:2107 OCEAN AVETELEPHONE:
(310) 399-3227
CITY:SANTA MONICASTATE: CAZIP CODE:
90405
CAPACITY:150CENSUS: 77DATE:
09/18/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Matan BurstynTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff did not provide resident assistance for an extended period of time after falling.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Monday, September 18, 2023. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Executive Director Matan Burstyn. LPA Bunker explained the purpose of today's visit.
The investigation consisted of the following: On 11/07/2022, and 09/18/2023, LPA Bunker conducted interviews with both staff and residents concerning the allegation, which suggested that facility staff had failed to provide timely assistance to a resident who had fallen. Staff 1 through Staff 3 (S1-S3) and Residents 1 through 8 (R1-R8) were interviewed. S1 disclosed that R1 had reported her fall on 10/05/2022; however, the specific time of the fall was not mentioned by R1. S1 also noted that S2 had previously assessed the functionality of R1's pendant before the incident date, certifying its proper working condition. However, on 10/05/2022, staff rechecked the pendant, finding it operational. In an effort to reassure R1, a new call pendant was promptly provided to her on the same day. Both S1 and S2 affirmed the functionality of the call button within R1's room. We toured R1's room for a health and safety check. See page 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
10/28/2022 and conducted by Evaluator Pamela Bunker
COMPLAINT CONTROL NUMBER: 11-AS-20221028153233

FACILITY NAME:BROOKDALE OCEAN HOUSEFACILITY NUMBER:
198204758
ADMINISTRATOR:PARK, THOMASFACILITY TYPE:
740
ADDRESS:2107 OCEAN AVETELEPHONE:
(310) 399-3227
CITY:SANTA MONICASTATE: CAZIP CODE:
90405
CAPACITY:150CENSUS: 77DATE:
09/18/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Matan BurstynTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff did not follow reporting requirements.
INVESTIGATION FINDINGS:
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Staff did not report an unusual incident reports regarding the incident.were submitted Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Monday, September 18, 2023. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Executive Director Matan Burstyn. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: LPA Bunker interviewed staff 1-2 (S1-S2) Olga Kirksey. Ms. Kirksey stated she wasn't working when R1 reported she had fallen on 10/05/2022. R1 did not state the time of the fall. Ms. Kirksey stated nurse Amanda Monroy checked R1's pendant prior to 10/05/2022, and it was in good working condition. On 10/05/2022 staff checked the pendant again after R1 stated it didn't work, and it did work. Staff gave R1 a new call pendant that same day to give her peace of mind. Ms. Kirksey stated staff had no control over the fall. Staff was unaware of the fall until the dining room staff went to R1's room that morning to serve R1 breakfast. R1's never called for help. See continued LIC9099-C page 2
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20221028153233
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BROOKDALE OCEAN HOUSE
FACILITY NUMBER: 198204758
VISIT DATE: 09/18/2023
NARRATIVE
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 Continued LIC9099-C page 2

Allegation: Facility staff did not follow reporting requirements.
On 10/05/2022 R1 fell around 11:00 P.M., and did not receive staff assistance until the following day near breakfast time around 7:45 A.M., When staff brought up R1 breakfast that is when staff contacted the nurse and Med Tech to come and assist R1. R1 reported staff offered to send R1 to the hospital but R1 refused and decided not to go to the hospital. Staff was unable to prevent the fall from happening. Staff did not know of the fall until the next morning. R1 never called for assistance. The facility staff failed to report the special incident report to Community Care Licensing according to Title 22 Regulations on Reporting Requirements.

Investigation revealed the following: On 11/07/2022, Interviews were conducted with staff 1-3 (S1-S3), and residents 1-8 (R2-R8), S1-S3 and R2-R8 stated staff provided the resident with immediate assistance. S1-S3 and R2-R8 stated residents never have to wait an extended period of time for assistance. S1-S3 stated the facility was unaware of the fall and the facility is fully staffed. Staff stated they had no control over the fall and could not have prevented the incident from happening. Staff did not report or submit a special incident report to the licensing agency or the person responsible for the resident within seven days of the occurrence regarding the incident

Based on LPA’s observations, interviews that were 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 LIC9099-D.

Appeal Rights were discussed, and copies of the Complaint Investigation Report LIC9099, LIC9099-C, and LIC9099-D were provided to the Executive Director.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20221028153233
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE OCEAN HOUSE
FACILITY NUMBER: 198204758
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2023
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements (a) (1)
A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. Staff did not report a special incident report that resident 1 had fallen on 10/05/2022.
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The facility should submit a written plan on Reporting Requirements to Community Care Licensing.

By the POC due date of 09/25/2023
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The violation poses a potential health and safety risk to 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: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20221028153233
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BROOKDALE OCEAN HOUSE
FACILITY NUMBER: 198204758
VISIT DATE: 09/18/2023
NARRATIVE
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Continued LIC9099-C page 2

During the tour, we tested R1's pendent and the room's call button, and both were found to be fully operational. S1 emphasized that the staff could not influence or prevent the fall incident, as they remained unaware of the event until the morning when the dining room staff visited R1's room to serve breakfast. R1 had not made any prior calls for assistance.

Investigation revealed the following: During interviews conducted with Staff 1 to Staff 3 (S1-S3), it was established that they had no prior knowledge of Resident 1's (R1) fall on the evening of October 5th, 2022, at approximately 11:00 P.M. S1-S3 attested that R1 did not seek assistance nor did she report the incident at that time. It was emphasized that the facility maintains 24-hour care, with staff members consistently patrolling the premises. None of the staff reported hearing any indications or witnessing any movement associated with a fall during that particular timeframe. S1-S3 were unanimous in affirming that immediate assistance was promptly provided to R1 once they became aware of the incident, which occurred the following morning when staff was delivering breakfast at approximately 7:45 A.M.

Upon being informed of R1's fall, staff promptly summoned the nurse and Med Tech to render aid. While staff offered to arrange for R1's transfer to a hospital, it was ultimately her decision to decline this option. Staff unequivocally asserted that they had no foreknowledge of the fall, as R1 did not contact them for assistance during the night.

S2, a member of the staff, conveyed that she conducted a comprehensive body examination of R1 and found no evidence of bruises or injuries resulting from the fall.

In R1's interview, she confirmed that on the date in question, October 5th, 2022, she had indeed experienced a fall within her room at approximately 11:00 P.M. However, she did not seek assistance at that time. Instead, it was during breakfast service at around 7:45 A.M. the following day that she brought the incident to the attention of staff, who promptly responded to her request for assistance. R1 reiterated that she did not make any prior attempts to contact staff for assistance.

Residents 2 through 8 (R2-R8), when interviewed, expressed a unanimous sentiment regarding the accessibility of staff assistance. They affirmed that staff members are readily available to provide aid, and residents do not experience undue delays in receiving assistance. Additionally, R2-R8 conveyed their satisfaction with the level of care and supervision provided, highlighting the absence of any noteworthy issues, problems, or concerns in this regard. These residents expressed a sense of comfort and safety within the facility. Staff stated they had no control over the occurrence of the fall, rendering them incapable of preventing the incident from transpiring.

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. An exit interview was conducted.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5