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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204758
Report Date: 09/29/2023
Date Signed: 09/29/2023 02:31:31 PM


Document Has Been Signed on 09/29/2023 02:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



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: 78DATE:
09/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Assoc. Executive Director Jayden Bettencourt. TIME COMPLETED:
02:25 PM
NARRATIVE
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On 09/29/23, Licensing Program Analyst (LPA) Jeremiah Randle conducted a case management visit in conjunction to a complaint visit conducted today at this facility. LPA met with Assoc. Executive Director Jayden Bettencourt and explained the purpose of the visit.

During a complaint investigation visit on 06/28/23 control # 11-AS-20230627152651, LPA identified Staff Trevor Weiss
in conjunction to a complaint visit conducted on 06/28/23. Staff Trevor Weiss does not have a Criminal Record Clearance associated to the facility named above in the Complaint.

During a complaint investigation visit on 06/28/23 control # 11-AS-20230627152651, LPA identified Administrator Matan Burstyn, or designated staff did not timely report incident of Financial Abuse to CDSS CCLD.


The licensee violated Title 22 Regulations 82711- Reporting Requirements and 87355 - Criminal Record Clearance California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D). Civil Penalties are Assessed.

An exit interview was conducted and a copy of this report and appeal rights provided to Assoc.Executive Director Jayden Bettencourt.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jeremiah RandleTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2023 02:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2023
Section Cited
CCR
87355(e)(2)

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Criminal Record Clearance: (e) All individuals
subject to a criminal record review pursuant to
Health and Safety Code Section 1569.17(b)

This requirement was not met as evidenced by
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Licensee will have cleared staff on
schedule, staff has been adequately
fingerprinted and background cleared and associated to facility. Per administrator staff Trevor Weiss has been terminated. Administrator to provide LPA updated LIC 500.
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Based on LPA observation and interview conducted, the licensee failed to ensure that staff Trevor Weiss was cleared or associated to the facility on 6/28/2023 and prior during employment.
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Type B
09/29/2023
Section Cited
CCR87211(a)(1)(d)

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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:Any incident which threatens the welfare, safety or health of any resident...This requirement was not met as evidenced by
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Administrator will provide LPA, per fax, staff meeting sign in sheet, regarding review of incident reporting requirement for Facilities per CDSS CCLD Regulations
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Based on LPA observation and records review conducted, the licensee failed to ensure that staff or administration reported incident in complaint referenced to CDSS CCLD
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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: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jeremiah RandleTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
LIC809 (FAS) - (06/04)
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