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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204758
Report Date: 07/27/2023
Date Signed: 07/27/2023 10:53:43 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
11/23/2022 and conducted by Evaluator Elizabeth Ceniceros
COMPLAINT CONTROL NUMBER: 11-AS-20221123152901
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:
07/27/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Matan Burstyn, Executive DirectorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by the "new" Administrator (A2: Matan Burstyn, Executive Director) whom RA interviewed and explained the purpose of today's visit. LPA/RA conducted a risk assessment prior to entering facility. A2 informed LPA/RA that the facility has no COVID cases to report at this time nor do the residents or staff have symptoms. The purpose for this subsequent visit is to deliver the findings pertaining to the above-mentioned allegation.

An initial 10-Day visit was conducted by LPA Martessa Brown on 12/01/22 with Staff #1 (S1: Amanda Monroy, Wellness Director) and was later met by Administrator (A1: Olga Kirskey, Executive Director). During this visit, LPA interviewed Administrator and Resident #1. LPA toured four (4) residents’ rooms on the 6th and 7th floors. LPA reviewed and obtained copies of the following documents: facility staff and resident rosters.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
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 3
Control Number 11-AS-20221123152901
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: 07/27/2023
NARRATIVE
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During today's subsequent visit, RA Ceniceros interviewed the "new" Maintenance Director (S3: Chris King). RA also re-visited Resident #1 Room #704 for observation of the repairs. RA Ceniceros obtained the following documents: updated staff and residents’ rosters and repair invoices (dated 05/04/23).

Regarding Allegation #1: this investigation revealed following a physical plant tour conducted on 12/01/22 by LPA Brown of a total of four (4) residents’ bedrooms on the 6th and 7th floors (included Resident #1’s Room), LPA observed a hole in the bathroom ceiling (above the shower) that had not been repaired and covered with a board due to a damaged water pipeline. The carpet in Room #704 was torn and worn out and a safety hazard.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of PHYSCIAL PLANT: Facility is in disrepair is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D).

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to the new Administrator (Matan Burstyn, Executive Director).

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20221123152901
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: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2023
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary, and in good repair at all times. Maintenance shall include profision of maintenance services and procedures for the safety and well-being of residents, employee and visitors. This was not met as evidence by:
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RA Elizabeth Ceniceros observed the ceiling and "new" flooring in Resident #1's Room #704 during the subsequent visit. POC was cleared by visit on 07/27/23.
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A hole in the bathroom ceiling (above the shower) had not been repaired and covered with a board due to a damaged water pipeline. The carpet was torn and worn out and a safety hazard LPA Martessa Brown's observations on 12/01/22.
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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) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3