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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204758
Report Date: 08/25/2023
Date Signed: 08/25/2023 10:37:22 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
06/14/2023 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20230614132722
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: 76DATE:
08/25/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Matan BurstynTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility staff did not respond to residents' call buttons in a timely manner
INVESTIGATION FINDINGS:
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On 08/25/23, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannouced subsequent visit to the facility listed above to deliver findings for a complaint. LPA Gibbs met with Administrator, Matan Burstyn, and explained the purpose of today's visit. During today's visit LPA toured the facility and rendered findings.
On the previous visit on 06/22/23, LPA Gibbs toured the physical plant with Administrator Burstyn. LPA Gibbs reviewed and received resident roster, staff roster, and staffing schedule. LPA Gibbs conducted interviews with Executive Director (S1), Staff (S2-S6), and Residents (R1-R8).

The investigation revealed the following:


CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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, 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
06/14/2023 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20230614132722

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: 76DATE:
08/25/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Matan BurstynTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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9
Facility staff failed to provide meal service to resident's in their rooms
INVESTIGATION FINDINGS:
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On 08/25/23, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannouced subsequent visit to the facility listed above to deliver findings for a complaint. LPA Gibbs met with Administrator, Matan Burstyn, and explained the purpose of today's visit. During today's visit LPA toured the facility and rendered findings.
On the previous visit on 06/22/23, LPA Gibbs toured the physical plant with Executive Director Burstyn. LPA Gibbs reviewed and received resident roster, staff roster, and staffing schedule. LPA Gibbs conducted interviews with Executive Director (S1), Staff (S2-S6), and Residents (R1-R8).

The investigation revealed the following:


CONTINUED ON LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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-20230614132722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BROOKDALE OCEAN HOUSE
FACILITY NUMBER: 198204758
VISIT DATE: 08/25/2023
NARRATIVE
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Allegation: Facility staff failed to provide meal service to residents in their rooms.

The allegation entails that staff forgot to turn in meal slips for resident who receive meals in their room, because of this three (3) residents did not receive their meals.

During interviews with staff (S1-S5), four (4) out of five (5) staff stated they check on residents who receive room service to ensure they have gotten their food, and if they did not, they will get it for them. Interviews with residents (R1-R6), six (6) out of six (6) residents say they get three (3) meals a day and snacks in-between meals. Five (5) out of six (6) residents (R1, R3, R4, R5 and R6) stated sometimes it takes a while for their food to come because they know staff are busy, but it does come. Resident R2 stated if it takes too long for their food to come up their caregiver will go down and go get it. During a tour of the dining room and meal service, LPA observed all residents got their meals and the cart for room service was on its way up to residents room.

Unsubstantiated Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20230614132722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BROOKDALE OCEAN HOUSE
FACILITY NUMBER: 198204758
VISIT DATE: 08/25/2023
NARRATIVE
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Allegation: Facility staff did not respond to residents’ call buttons in a timely manner.

The allegation entails that a residents pressed their call light for assistance to the restroom and the resident had to wait thirty (30) minutes for assistance.

Interviews with staff A1 and S1-S5 revealed the following. During interview Administrator (A1) stated staff respond to pendant call buttons as soon as possible. Staff S1 stated they try to respond as soon as possible but it they are assisting another resident it could take some time. Staff (S2-S5), four (4) out of four (4) stated, they try to go as soon as possible but it can take 15 to 40 minutes before we are able to respond. Interviews with residents (R1-R6) revealed the following. Residents R1 stated the soonest a caregiver has come to assist, after pressing the call button, was 10 minutes and the longest has been over an hour. R1 also stated, they had to wheel themselves to the door and was yelling for help, and still no one came. R1 stated they had to call their family who called the front desk for R1 to get assistance. Resident R2 stated they hired a private caregiver because they tried the pendant, but staff were busy, and R2 couldn’t wait. Interviews with residents R 3 and R4, two (2) out of two (2) stated staff never come when they press their pendants. Resident (R5) during interviews stated, when they press their pendant, it takes 30-40 minutes before a caregiver comes. Additionally, R5 stated they now call the front desk when they need assistance because the caregivers take to long. During an interview, LPA and R2 pressed the call button and it took staff 23 minutes for staff to respond to the call button.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20230614132722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BROOKDALE OCEAN HOUSE
FACILITY NUMBER: 198204758
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in all Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
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The Administrator will provide a written plan of action explaining what steps they are going to do to ensure residents call buttons are answered within a timely manner.

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(4) to care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
Based on interviews and observation the Licensee did not ensure residents call
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buttons were answered within a timely
manner. This possesses 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5