Inspection Reports for
Brookdale Ocean House
2107 Ocean Ave, Santa Monica, CA 90405, United States, CA, 90405
Back to Facility ProfileCitations (last 5 years)
Citations (over 5 years)
1.8 citations/year
Citations are regulatory findings recorded during state inspections.
55% better than California average
California average: 4 citations/yearCitations per year
8
6
4
2
0
Occupancy
Latest occupancy rate
75% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 112
Capacity: 150
Citations: 0
Date: Sep 13, 2025
Visit Reason
The inspection was an unannounced annual required visit conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with all applicable regulations. No deficiencies were identified during this inspection visit.
Report Facts
Residents on hospice care: 3
Hospice waiver capacity: 5
Apartment units: 116
Fire drills dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Lee | Executive Director / Administrator | Met with Licensing Program Analyst during inspection and named in report. |
| Sandra Solarano | Resident Engagement Manager | Met with Licensing Program Analyst during inspection. |
| Ernand Dabuet | Licensing Program Analyst | Conducted the inspection visit. |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 150
Citations: 0
Date: Jul 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-05-12 regarding staffing adequacy, resident care, supervision of fall-risk residents, and response to call buttons.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included insufficient staffing, residents left soiled, inadequate supervision of fall-risk residents, and delayed response to call buttons. Evidence gathered did not support these claims.
Findings
The investigation found the allegations unsubstantiated based on interviews with residents and staff, observations, and record reviews. Staffing was deemed adequate, residents were not left soiled for extended periods, fall-risk residents were properly supervised, and call buttons were answered timely.
Report Facts
Residents interviewed: 12
Staff interviewed: 9
Residents reporting adequate staffing: 9
Residents reporting not left soiled: 9
Residents reporting proper supervision: 9
Residents reporting timely call button response: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Lee | Administrator | Met during the investigation and exit interview |
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Cifuentes | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 150
Citations: 0
Date: May 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2025-05-12 regarding staffing adequacy, resident supervision, and timely response to call buttons.
Complaint Details
The complaint included allegations that the licensee did not ensure enough staff to meet residents' needs, staff left residents soiled for extended periods, staff did not properly supervise residents at fall risk, and staff did not answer call buttons timely. The investigation found insufficient evidence to substantiate these allegations.
Findings
The investigation included interviews with residents and staff, observations, and record reviews. The evidence gathered indicated that the allegations were unsubstantiated, with staff providing adequate care, supervision, and timely assistance to residents.
Report Facts
Residents interviewed: 12
Staff interviewed: 9
Residents reporting adequate staffing: 9
Residents reporting not left soiled: 9
Residents reporting assistance with needs: 9
Residents reporting timely call button response: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Lee | Administrator | Met during the investigation and informed of the visit purpose |
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 150
Citations: 0
Date: Mar 27, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to multiple allegations regarding unsanitary meal preparation, improper food storage, inadequate food service, and facility equipment disrepair at Brookdale Ocean House.
Complaint Details
The complaint investigation was triggered by allegations including unsanitary meal preparation, improper food storage, inadequate food service, and equipment disrepair. After thorough investigation including staff and resident interviews, kitchen and dining area tours, and record reviews, all allegations were found unsubstantiated.
Findings
The investigation found no preponderance of evidence to support any of the allegations. Interviews, observations, and record reviews indicated that food handling, storage, sanitation practices, food service adequacy, and equipment condition met regulatory standards. All allegations were unsubstantiated and no deficiencies were cited.
Report Facts
Staff with food handler certifications: 15
Staff interviews: 6
Resident interviews: 8
Facility capacity: 150
Census: 99
Chipped plates observed: 3
Kitchen cleaning schedule dates: 6
Third-party inspection date: Mar 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Lee | Executive Director | Met with Licensing Program Analysts during investigation and exit interview. |
| Regina Cloyd | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Jose Anguiano | Licensing Program Analyst | Assisted in conducting the complaint investigation. |
| Esmeralda Ornelas | Business Office Manager | Met with LPAs during investigation and provided information. |
| Pro Jenn O'Brien Chavez | Sales Manager | Met with LPAs during investigation and provided information. |
| Ulysses Coronel | Supervisor | Supervisor overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 150
Citations: 0
Date: Dec 4, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-10-25 regarding allegations that facility staff did not dispense medications as prescribed and did not respond to a resident's call button.
Complaint Details
The complaint involved two allegations: 1) Facility staff did not dispense medications as prescribed, specifically medications #1, #2, and #3 for Resident #1. 2) Facility staff did not respond to Resident #1's call button, with reports of three unwitnessed falls and delayed response times ranging from 18 to 32 minutes. After review of records, interviews, and observations, both allegations were found unsubstantiated.
Findings
The investigation found no preponderance of evidence to support the allegations that medications were not dispensed as prescribed or that staff failed to respond to the resident's call button. Both allegations were determined to be unsubstantiated and no deficiencies were cited.
Report Facts
Medication administration exceptions: 1
Medication administration exceptions: 2
Medication administration exceptions: 2
Medication administration exceptions: 11
Medication administration: 1
Resident call response delay: 5
Call response time range (minutes): 18
Call response time range (minutes): 32
Resident falls: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Lee | Administrator | Met during investigation and provided information regarding call button response |
| Regina Cloyd | Licensing Program Analyst | Conducted the complaint investigation |
| Ulysses Coronel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 85
Capacity: 150
Citations: 0
Date: Aug 28, 2024
Visit Reason
The visit was an unannounced one-year inspection to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be in full compliance with no deficiencies observed. All resident rooms, common areas, and safety equipment were inspected and found to be properly maintained and hazard-free.
Report Facts
Resident records reviewed: 8
Staff records reviewed: 8
Apartment units: 116
One-bedroom units: 16
Studio units: 92
Deluxe studio units: 7
Hospice waiver capacity: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Lee | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Sparkle Day | Licensing Program Analyst | Conducted the unannounced inspection visit |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 150
Citations: 0
Date: Jul 19, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-08-15 regarding staff mishandling medication, inadequate supervision, and delayed medical attention for a resident.
Complaint Details
The complaint involved three allegations: staff mishandling a resident's medication, inadequate supervision, and delayed medical attention. Interviews and record reviews did not support these allegations, resulting in an unsubstantiated finding.
Findings
The investigation found all allegations to be unsubstantiated based on interviews with staff and residents and review of medication administration records and staff training. No deficiencies were cited.
Report Facts
Capacity: 150
Census: 82
Estimated Days of Completion: 90
Number of residents interviewed: 8
Number of staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mario Leon | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Helen Lee | Executive Director | Facility representative met during the investigation |
| Thomas Park | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 150
Citations: 0
Date: Jan 10, 2024
Visit Reason
The visit was an unannounced complaint investigation initiated due to allegations regarding elevator maintenance, staff response to call buttons, and timely meal provision for residents.
Complaint Details
The complaint investigation was triggered by allegations that the licensee does not keep facility elevators maintained in operating condition, staff do not respond to residents' call buttons in a timely manner, and staff do not provide residents with timely meals. After interviews with residents and staff, record reviews, and observations, all allegations were found unsubstantiated.
Findings
The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove any violations occurred. All three allegations—elevator maintenance, staff response to call buttons, and timely meal provision—were determined to be unsubstantiated.
Report Facts
Facility capacity: 150
Census: 75
Residents with oxygen: 1
Residents with dementia: 1
Residents with wheelchairs: 9
Residents with diapers: 2
Staff interviewed: 7
Residents interviewed: 8
Elevator modernization proposal amount: 592580
Elevator inspection dates: 2
Pagers in use: 4
Meal service staff: 3
Meal service cooks: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Espana | Licensing Program Analyst | Conducted the complaint investigation visit |
| Thomas Park | Administrator | Facility administrator involved in interviews and investigation |
| Helen Lee | Administrator | Met with Licensing Program Analyst during visit |
| Ulysses Coronel | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 150
Citations: 0
Date: Nov 15, 2023
Visit Reason
An unannounced complaint investigation visit was conducted on 11/15/2023 following a complaint received on 11/07/2023 regarding allegations of staff not treating residents with dignity and respect, inadequate food service, uncomfortable environment, failure to issue refunds, and not meeting residents' needs.
Complaint Details
The complaint investigation was initiated based on multiple allegations including staff not treating residents with dignity and respect, inadequate food service, uncomfortable environment, failure to issue refunds, and not meeting residents' needs. After interviews and evidence review, all allegations were determined to be unsubstantiated.
Findings
The investigation included interviews with residents, staff, and a witness, as well as facility observations and record reviews. All allegations were found to be unsubstantiated due to lack of preponderance of evidence to prove violations occurred.
Report Facts
Residents interviewed: 5
Staff interviewed: 5
Witness interviewed: 1
Facility capacity: 150
Facility census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Espana | Licensing Program Analyst | Conducted the complaint investigation |
| Ulysses Coronel | Supervisor | Supervisor of the investigation |
| Thomas Park | Administrator | Facility administrator mentioned in report |
| Helen Lee | Met with Licensing Program Analyst during visit | |
| S1 | Interviewed regarding refund allegation | |
| R1 | Resident involved in refund allegation |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 150
Citations: 0
Date: Nov 2, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-09-05 regarding staff not providing fluids when requested, not ensuring privacy, and not treating residents with dignity and respect.
Complaint Details
The complaint involved allegations that staff did not provide fluids when requested, did not ensure privacy, and did not treat residents with dignity and respect. Interviews with residents and staff, observations, and record reviews did not support these allegations. The complaint was deemed unsubstantiated.
Findings
The investigation included interviews with residents and staff, observations, and record reviews. The allegations were found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred. No deficiencies were cited.
Report Facts
Residents interviewed: 8
Staff interviewed: 7
Complaint received date: Sep 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lourdes Montoya | Licensing Program Analyst | Conducted the complaint investigation and visit |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Helen Lee | Executive Director/Administrator | Facility representative met during the investigation |
| Thomas Park | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 150
Citations: 2
Date: Sep 29, 2023
Visit Reason
A case management visit was conducted in conjunction with a complaint investigation visit triggered by a complaint regarding staff criminal record clearance and failure to timely report an incident of financial abuse.
Complaint Details
The complaint investigation identified that staff Trevor Weiss did not have a criminal record clearance associated with the facility and that the administrator or designated staff did not timely report an incident of financial abuse to CDSS CCLD.
Findings
The licensee was found to have deficiencies including failure to ensure staff Trevor Weiss had a valid criminal record clearance and failure to timely report an incident of financial abuse to CDSS CCLD. Citations were issued and civil penalties assessed.
Citations (2)
Failure to ensure staff Trevor Weiss was cleared or associated to the facility with a criminal record clearance as required.
Failure to timely report an incident of financial abuse to CDSS CCLD as required.
Report Facts
Capacity: 150
Census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Trevor Weiss | Named in deficiency for lacking criminal record clearance | |
| Matan Burstyn | Administrator | Named in deficiency for failure to timely report financial abuse incident |
| Jayden Bettencourt | Associate Executive Director | Met with Licensing Program Analyst during visit |
| Jeremiah Randle | Licensing Program Analyst | Conducted the case management and complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 150
Citations: 1
Date: Sep 18, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff did not provide resident assistance for an extended period of time after a resident fell and failed to follow reporting requirements.
Complaint Details
The complaint alleged that facility staff did not provide timely assistance to a resident who had fallen and did not follow reporting requirements. The allegation of delayed assistance was found unsubstantiated due to lack of evidence that staff delayed assistance. The allegation of failure to report the incident was substantiated.
Findings
The investigation found that the resident fell on 10/05/2022 around 11:00 PM but did not call for assistance and staff were unaware of the fall until the following morning at breakfast time. Staff provided immediate assistance once aware. The facility failed to submit a special incident report within seven days as required by regulations. The allegation of delayed assistance was unsubstantiated, but the failure to report was substantiated.
Citations (1)
Staff did not report a special incident report that resident 1 had fallen on 10/05/2022 within seven days as required by Title 22 regulations.
Report Facts
Capacity: 150
Census: 77
Deficiencies cited: 1
Plan of Correction Due Date: Sep 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Matan Burstyn | Executive Director | Met with the Licensing Program Analyst during the visit |
| Olga Kirksey | Staff interviewed regarding the incident and reporting | |
| Amanda Monroy | Nurse | Checked the resident's pendant prior to the fall date |
Inspection Report
Annual Inspection
Census: 77
Capacity: 150
Citations: 0
Date: Sep 2, 2023
Visit Reason
The inspection was an unannounced Required - 1 Year Annual visit to evaluate the facility's compliance using the new CARE Inspection Tools.
Findings
The facility was found to be clean, well-maintained, and in compliance with Title 22 regulations. No deficiencies or citations were observed or issued during the inspection.
Report Facts
Apartments inspected for hot water temperature: 9
Facility capacity: 150
Resident census: 77
Apartment units: 116
Fire/emergency drill date: Aug 28, 2023
Floors in building: 10
Resident apartments inspected: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the inspection and toured the facility. |
| Matan Burstyn | Executive Director | Met with the Licensing Program Analyst and participated in the inspection. |
| Jesus Correa | Staff member met during the inspection tour. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 150
Citations: 1
Date: Aug 25, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-06-14 regarding failure of facility staff to respond timely to residents' call buttons and failure to provide meal service to residents in their rooms.
Complaint Details
The complaint investigation was substantiated for the allegation that facility staff did not respond to residents' call buttons in a timely manner, with evidence including resident and staff interviews and direct observation of delayed response times. The allegation that staff failed to provide meal service to residents in their rooms was unsubstantiated due to lack of sufficient evidence.
Findings
The investigation substantiated that facility staff did not respond to residents' call buttons in a timely manner, with delays ranging from 15 to over 60 minutes, posing a potential health and safety risk. The allegation regarding failure to provide meal service to residents in their rooms was unsubstantiated as residents reported receiving meals and snacks, although sometimes delayed due to staff being busy.
Citations (1)
Failure to ensure residents' call buttons were answered within a timely manner, posing a potential health and safety risk.
Report Facts
Census: 76
Total Capacity: 150
Plan of Correction Due Date: Sep 1, 2023
Call button response delay: 30
Call button response delay observed: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Thomas Park | Administrator | Facility administrator involved in interviews and findings |
| Matan Burstyn | Met with Licensing Program Analyst during inspection visit |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 150
Citations: 1
Date: Jul 27, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation received on 11/23/2022 that the facility is in disrepair.
Complaint Details
The complaint investigation was substantiated. The allegation of the facility being in disrepair was confirmed based on observations, interviews, and document reviews. The preponderance of evidence standard was met.
Findings
The investigation substantiated the allegation that the facility was in disrepair, specifically noting a hole in the bathroom ceiling above the shower and torn, worn-out carpet in Resident #1's room, which posed a safety hazard. A citation was issued for failure to maintain the facility in a clean, safe, sanitary, and good repair condition.
Citations (1)
87303(a) Maintenance and Operation: The facility was not clean, safe, sanitary, and in good repair as evidenced by a hole in the bathroom ceiling above the shower and torn, worn-out carpet posing a safety hazard.
Report Facts
Capacity: 150
Census: 76
Plan of Correction Due Date: Aug 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Ceniceros | Licensing Program Analyst / Retired Annuitant | Evaluator who conducted the complaint investigation and observed deficiencies |
| Matan Burstyn | Executive Director | New Administrator interviewed during the investigation and recipient of the exit interview |
| Chris King | Maintenance Director | Interviewed during the subsequent visit and observed repairs |
| Amanda Monroy | Wellness Director | Staff interviewed during initial 10-day visit |
| Olga Kirskey | Executive Director | Administrator during initial 10-day visit |
| Janae Hammond | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 150
Citations: 1
Date: Jun 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the licensee does not ensure the facility is adequately staffed to meet residents’ needs.
Complaint Details
The complaint alleged that the licensee does not ensure the facility is adequately staffed to meet residents’ needs. The allegation was substantiated based on interviews, observations, and record reviews.
Findings
The investigation found that staffing levels were insufficient to meet the daily needs of residents, with caregivers assisting multiple residents with showers, dressing, grooming, toileting, and meal escorting, resulting in staff not always being able to assist residents when needed. The allegation was substantiated and citations were issued.
Citations (1)
Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by insufficient number of competent staff during 8-hour shifts, posing potential health and safety risks.
Report Facts
Capacity: 150
Census: 67
Deficiency Type: 1
Plan of Correction Due Date: Jun 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Matan Burstyn | Executive Director | Met with Licensing Program Analyst during the investigation and provided information on staffing |
| Thomas Park | Administrator | Facility Administrator named in the report |
| Eva M Alvarez | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 150
Citations: 1
Date: Mar 29, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted to address the allegation that facility equipment is in disrepair.
Complaint Details
The complaint was substantiated. The allegation was that facility equipment is in disrepair, specifically one elevator being out of service for months and washing machines frequently needing repair. Residents and staff confirmed the issues, and documentation showed ongoing maintenance and repair efforts with delays due to parts availability.
Findings
The investigation found that one elevator has been out of service for months due to parts being on back order, and washing machines were frequently out of service. Residents and staff confirmed these issues, and records showed frequent service calls. Plans are in place to replace both elevators with construction starting April 1, 2023.
Citations (1)
Facility shall be clean, safe, sanitary and in good repair at all times; maintenance shall include provision of maintenance services and procedures for safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by elevator and washing machine disrepair.
Report Facts
Facility capacity: 150
Census: 72
Plan of Correction due date: Apr 7, 2023
Elevator modernization start date: Apr 1, 2023
Elevator modernization completion date: Apr 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Holly Rice | Associate Executive Director | Interviewed during investigation and recipient of report |
| Thomas Park | Administrator | Facility administrator listed in report |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| Matan Burstyn | Executive Director (incoming) | New Executive Director starting 03/30/23, planning elevator replacement announcement |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 150
Citations: 0
Date: Oct 3, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility did not safeguard a resident's personal belongings.
Complaint Details
The complaint alleged that the facility did not safeguard a resident's personal belongings. Interviews with staff and residents indicated that personal belongings were generally safeguarded. The resident who reported missing items had no proof of who took them, and the caregiver suspected was no longer employed. The facility provided a personal property document which did not list the missing items. The allegation was deemed unsubstantiated.
Findings
The investigation included interviews with staff and residents and a review of evidence. The allegation was found to be unsubstantiated due to insufficient evidence to prove the claim, although the resident believed personal items were missing from her room over two years ago during COVID-19.
Report Facts
Capacity: 150
Census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit |
| Joshua Castillo | Associate Executive Director | Interviewed during the investigation regarding resident belongings |
| Olga Kirksey | Executive Director | Interviewed during the investigation |
| Stephanie Cifuentes | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 150
Citations: 0
Date: Aug 11, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-07-11 regarding the facility's adherence to the Admission Agreement, residents' hygiene needs, and staff meeting residents' needs while in care.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to adhere to the Admission Agreement, unmet resident hygiene needs, and staff not meeting resident needs. The Licensing Program Analyst conducted interviews with residents (R1-R9) and staff (S1-S4), reviewed service documents and Personal Service Plans, and conducted a plant inspection. No evidence was found to support the allegations.
Findings
The investigation found no evidence or witnesses supporting the allegations. Interviews with residents and staff, document reviews, and a plant inspection revealed that the facility adhered to the Admission Agreement, residents' hygiene needs were met, and staff met residents' needs. All allegations were determined to be unsubstantiated and no deficiencies were found.
Report Facts
Capacity: 150
Census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Don Senaha | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joshua Castillo | Associate Executive Director | Participated in the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 150
Citations: 1
Date: Aug 9, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted to address the allegation that the facility elevator(s) are not maintained in operating condition.
Complaint Details
The complaint was substantiated. Interviews with 8 residents and 5 staff confirmed the elevators have been broken for approximately three months. Records showed multiple repair attempts and callbacks. The elevators had been out of service on multiple occasions, including a prior incident where residents were trapped inside.
Findings
The investigation found the allegation substantiated based on interviews with 8 residents and 5 staff who all confirmed the elevators have been broken down for about three months, causing safety and accessibility concerns. Record review showed frequent elevator repairs and observed signage indicating one elevator was out of service.
Citations (1)
Facility failed to maintain elevator(s) in operating condition, violating CCR 87303(a) requiring the facility to be clean, safe, sanitary and in good repair at all times.
Report Facts
Residents interviewed: 8
Staff interviewed: 5
Elevator repairs recorded: 6
Elevator callbacks recorded: 7
Facility capacity: 150
Current census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Troy Agard | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ulysses Coronel | Licensing Program Manager | Oversaw the complaint investigation |
| Joshua Castillo | Associate Executive Director | Facility representative interviewed during investigation |
| Thomas Park | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 150
Citations: 0
Date: May 18, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident was charged for services not received.
Complaint Details
The complaint alleged that a resident was charged for services not received. The investigation included interviews with facility staff and review of resident records. It was found that the resident was considered a community member as of the admission agreement date and charges started accruing then. The resident's insurance claim was denied, and the resident was responsible for repayment. The allegation was unsubstantiated.
Findings
The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violation occurred. The allegation was determined to be unsubstantiated and no deficiencies were cited.
Report Facts
Capacity: 150
Census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jey Cardenas | Licensing Program Analyst | Conducted the complaint investigation |
| Thomas Park | Administrator | Facility administrator involved in the investigation |
| Joshua Castillo | Associate Executive Director | Interviewed during the investigation |
| Thomas Rekowski | Former Executive Director | Interviewed via telephone during the investigation |
Inspection Report
Annual Inspection
Census: 91
Capacity: 150
Citations: 0
Date: Aug 25, 2021
Visit Reason
An unannounced Required - 1 Year Annual visit was conducted focusing primarily on Infection Control measures using the CARE Inspection Tools.
Findings
The facility was found to be in compliance with all Title 22 regulated areas, including safety, sanitation, infection control, and emergency preparedness. No deficiencies were cited during the inspection.
Report Facts
Facility capacity: 150
Census: 91
Fire/emergency drill date: Aug 16, 2021
Apartment units: 116
Apartment types: 16
Apartment types: 92
Apartment types: 8
Hot water temperature range: 112.5
Hot water temperature range: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the inspection and evaluation |
| Thomas Park | Administrator | Facility administrator named in report header |
| Tom Rekowski | Executive Director | Provided information during inspection and participated in tour |
| Rose Linesch | Lead Receptionist | Spoke with Licensing Program Analyst during risk assessment |
| Angela J Kendrick | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Capacity: 150
Citations: 0
Date: Aug 24, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations including resident death while in care, improper maintenance of resident rooms, inadequate assistance to residents, and resident mistreatment.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included resident death due to neglect, improper room maintenance, inadequate assistance, and mistreatment. Interviews with residents, staff, and review of records found no evidence to support these allegations.
Findings
The investigation found no sufficient evidence to support any of the allegations. The resident death was due to COVID-19 related pneumonia after being out of facility care. Residents' rooms were properly maintained, staff properly assisted residents, and no mistreatment was found.
Report Facts
Facility capacity: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Robert Kujawa | IB Investigator | Conducted interviews and record reviews related to the complaint investigation |
| Thomas Rekowski | Executive Director | Met with Licensing Program Analyst during the investigation |
| Eva M Alvarez | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 150
Citations: 0
Date: Jun 9, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted to investigate the allegation that the facility did not release a resident's records to the resident's representative.
Complaint Details
The allegation was that the facility did not release resident's records to the resident representative. The investigation found that the facility received a records request from an authorized legal representative, responded by providing the records in parts, and residents confirmed access to their records. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included interviews with staff, residents, and the Executive Director, as well as a review of records. The evidence did not substantiate the allegation, as records were provided to the authorized representative after a request, and residents confirmed access to their records.
Report Facts
Capacity: 150
Census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tom Rekowski | Executive Director | Interviewed during the complaint investigation regarding records request |
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 150
Citations: 1
Date: May 7, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations of insufficient staffing to meet residents' needs and untrained staff at the facility.
Complaint Details
The complaint investigation was initiated based on allegations of insufficient staffing and untrained staff. The untrained staff allegation was substantiated, while the insufficient staffing allegation was unsubstantiated.
Findings
The allegation of untrained staff was substantiated based on interviews, observations, and records review, revealing staff had been scheduled for tasks without proper training. The allegation of insufficient staffing was unsubstantiated as evidence showed staffing levels were adequate for the current resident census and needs.
Citations (1)
Failure to ensure all personnel were given on the job training or had related experience for their assigned tasks.
Report Facts
Staff trained: 7
Residents interviewed: 8
Staff interviewed: 6
Caregivers on duty: 3
Caregivers on duty: 2
Caregivers on duty: 1
Facility capacity percentage: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Tom Rekowski | Executive Director | Interviewed during the investigation and provided information on staffing and training |
| Eva M Alvarez | Supervisor | Supervisor overseeing the complaint investigation |
| Thomas Park | Administrator | Facility administrator named in the report |
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