Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. The most recent report from September 19, 2025, cited a minor deficiency related to missing annual training records for four staff members, but no severe issues or enforcement actions were noted. A prior complaint investigation in April 2025 substantiated a serious safety issue when a resident eloped unsupervised and sustained a fractured hip, highlighting a lapse in staff supervision and alarm response. Earlier annual inspections identified some personnel documentation and medical assessment deficiencies, but these were isolated and did not involve enforcement or fines. The facility’s record shows improvement in recent years, with the latest inspection showing only a minor training documentation issue after previous more significant findings.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
98% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 49
Capacity: 50
Deficiencies: 1
Sep 19, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements at Welbrook Senior Living Santa Monica facility.
Findings
The facility was generally well maintained with adequate supplies and safety equipment. However, a deficiency was cited due to the absence of annual training records for four staff members, which is a violation of personnel training requirements.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Four out of four staff members (S1, S2, S3, and S4) did not have proof of initial and annual training in their files, nor could administration provide proof of training, posing a potential health, safety, or personal rights risk to persons in care. | Type B |
Report Facts
Staff without training records: 4
Facility capacity: 50
Census: 49
Food supply duration: 5
Food supply duration: 7
Fire drill date: Sep 2, 2025
Plan of Correction due date: Sep 26, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Catalina Cole | Administrator | Named in relation to the deficiency and plan of correction. |
| Bernadette Allen | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Chhandita Panday | Wellness Director | Met with Licensing Program Analyst at the start of the inspection. |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 50
Deficiencies: 2
Apr 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that a resident sustained a serious injury while in care and that the resident left the facility unsupervised.
Findings
The investigation substantiated that a resident eloped from the facility unsupervised, resulting in a serious injury (fractured hip). It was found that staff were not present on the second floor during the incident and did not hear the alarm. Another allegation that staff failed to report the resident injury to the responsible party was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that a resident sustained a serious injury while eloping from the facility unsupervised. The resident suffered an intertrochanteric osteoporotic hip fracture after being found in an alleyway. The investigation found staff were not present on the second floor and did not hear the alarm during the incident. The allegation that staff failed to report the injury to the responsible party was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not ensure the safety of a resident who wandered out of the facility unsupervised, resulting in a serious injury during elopement. | Type B |
| Delayed egress devices did not substitute for trained staff to meet the care and supervision needs of residents; staff were not on the second floor during the incident and did not hear the alarm. | Type B |
Report Facts
Capacity: 50
Census: 47
Deficiencies cited: 2
Plan of Correction Due Date: Apr 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Cole | Executive Director | Interviewed during investigation and named in findings related to resident elopement and supervision |
| Deborah Lee | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Annual Inspection
Census: 45
Capacity: 50
Deficiencies: 4
Sep 21, 2024
Visit Reason
An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations for the facility.
Findings
The facility was inspected thoroughly including resident rooms, physical plant, and infection control practices. Several deficiencies were identified related to staff criminal record clearance, medical assessments for residents with dementia, staff first aid/CPR certification, and personnel health screenings.
Severity Breakdown
Type A: 1
Type B: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Staff #6 did not have criminal record clearance transfer as required. | Type A |
| Residents #2 and #4 diagnosed with dementia did not have current medical assessment and reappraisal on file. | Type B |
| Staff #3, #4, and #5 did not have current First Aid/CPR certificates on file. | Type B |
| Staff #3 did not have a health screening nor TB test results on file. | Type B |
Report Facts
Capacity: 50
Census: 45
POC Due Date: Sep 22, 2024
POC Due Date: Oct 12, 2024
Fine Amount: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Catalina Cole | Administrator | Named as facility administrator with pending certificate renewal |
| Maria Cox | Activities Director | Met with Licensing Program Analyst during inspection |
| Maria Schwartz | Business Office Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Ernand Dabuet | Licensing Program Analyst | Conducted the inspection and authored the report |
| Janae Hammond | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 50
Deficiencies: 0
Nov 8, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff imposed restrictions on a resident's visitors and did not allow the resident to receive phone calls.
Findings
The investigation found the allegations to be unsubstantiated. Interviews and document reviews showed that restrictions were due to a conservator's directive to preclude a specific reporting party from visiting or calling a resident, not due to facility staff actions.
Complaint Details
The complaint alleged that staff imposed restrictions on a resident's visitors and did not allow the resident to receive phone calls. The investigation included interviews with the administrator, staff, residents, and the conservator, as well as review of emails and court documents. The conservator had precluded the reporting party from visiting and calling the resident due to concerns about the resident's agitation. The allegations were found to be unsubstantiated.
Report Facts
Capacity: 50
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| David Cole | Administrator | Interviewed during the investigation and named in findings |
Inspection Report
Annual Inspection
Census: 43
Capacity: 50
Deficiencies: 0
Oct 4, 2023
Visit Reason
An unannounced Required – 1 Year Inspection was conducted to evaluate compliance with licensing requirements and facility standards.
Findings
The facility was found to be in compliance with licensing requirements, including adequate resident accommodations, safe and clean common areas, proper functioning of bathrooms and safety equipment, sufficient food supplies, and staff records with current certifications and clearances.
Report Facts
Licensed hospice with dementia waiver: 15
Staff records reviewed: 5
Resident records reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Cole | Administrator & Vice President of Operations | Met with Licensing Program Analyst during inspection. |
| Leandro Socorro | Licensing Program Analyst | Conducted the inspection. |
| Ulysses Coronel | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 50
Deficiencies: 0
Sep 7, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff do not allow residents to make and receive confidential phone calls.
Findings
The investigation included interviews with the administrator, staff, and residents, as well as review of relevant documents and a physical tour. The evidence did not support the allegation, and all interviewed residents stated they could access the telephone privately without staff interference. The allegation was found to be unsubstantiated.
Complaint Details
Allegation: Staff do not allow resident to make and receive confidential phone calls. The complaint alleged that staff snatched the telephone away from a resident. After investigation, including interviews and records review, the allegation was found to be unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 50
Census: 42
Resident interviews: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dana Anderson | Administrator | Met with Licensing Program Analyst during investigation and provided statements regarding telephone access and resident rights |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 50
Deficiencies: 0
May 26, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff double diaper residents and that staff do not meet training requirements.
Findings
The investigation found no sufficient evidence to support the allegations. Interviews with residents, staff, and the Wellness Director, as well as record reviews, indicated that staff do not double diaper residents and meet training requirements. No deficiencies or citations were observed or issued during the visit.
Complaint Details
The complaint investigation was unsubstantiated based on observations, interviews, and record review. Allegations included staff double diapering residents and inadequate staff training, both of which were not supported by evidence.
Report Facts
Capacity: 50
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dana Anderson | Executive Director | Met with Licensing Program Analyst during the investigation and named in the exit interview |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation |
| Chhadita Panday | Wellness Director | Interviewed during the investigation regarding staff training and resident care |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 50
Deficiencies: 0
Aug 22, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility telephone was in disrepair and it was impossible to get a hold of staff.
Findings
The investigation found no evidence to support the allegation that the facility telephone was in disrepair. Staff and residents confirmed the phone system was operational, and telephone logs showed calls were received. The allegation was determined to be unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged that the facility telephone was in disrepair, making it impossible to reach staff, with the issue persisting for three months. The allegation was unsubstantiated based on interviews, document review, and observations.
Report Facts
Capacity: 50
Census: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Beck | Executive Director | Greeted Licensing Program Analyst and participated in exit interview |
| Henry Rivas | Business Office Manager | Conducted facility tour with Licensing Program Analyst |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 50
Deficiencies: 0
Jun 7, 2022
Visit Reason
An unannounced complaint investigation was conducted to investigate multiple allegations received on 2022-02-02 regarding staff not following hospice care plans, performing medical procedures, medication management, call button response times, reporting changes in resident condition, evacuation chairs, door repairs, staff training, and incident reporting.
Findings
The investigation included interviews, facility tours, and document reviews. No sufficient evidence was found to support any of the allegations. The department concluded that the allegations were unsubstantiated after reviewing hospice care plans, medication records, staff training, evacuation equipment, and incident reporting procedures.
Complaint Details
The complaint investigation was triggered by multiple allegations including failure to follow hospice care plans, improper medical procedures, medication errors, delayed call button responses, failure to inform physicians of condition changes, lack of evacuation chairs, disrepair of delayed egress doors, inadequate staff training, and failure to report incidents. All allegations were found unsubstantiated based on interviews, document reviews, and observations.
Report Facts
Facility capacity: 50
Census: 35
Number of delayed egress doors: 8
Number of stairwells with evacuation chairs: 2
Number of staff interviewed: 6
Number of residents interviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Cole | Administrator | Spoke regarding medication management and door maintenance |
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Chhandita Panday | Wellness Director / Nurse | Interviewed regarding hospice care plans, medical procedures, and call button system |
| Kristin Beck | Facility representative present at exit interview |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 50
Deficiencies: 0
Apr 7, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations including staff mismanaging residents' medications, residents' hygiene needs not being met, and staff not allowing residents to have visitations.
Findings
The investigation found no evidence to support the allegations. Medication administration records, interviews with staff, residents, and witnesses indicated no issues with medication management, hygiene assistance, or visitation restrictions. The allegations were determined to be unsubstantiated due to lack of sufficient evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff mismanaging residents' medications, residents' hygiene needs not being met, and staff not allowing residents to have visitations. Interviews and record reviews did not find sufficient evidence to support these allegations.
Report Facts
Capacity: 50
Census: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Cole | Administrator | Interviewed regarding allegations and facility operations |
| Chhandita Panday | Wellness Director | Interviewed and conducted COVID-19 risk assessment during investigation |
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Annual Inspection
Census: 30
Capacity: 50
Deficiencies: 0
Oct 13, 2021
Visit Reason
The inspection was an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool.
Findings
The facility was found to be in compliance with infection control practices, including screening protocols, PPE availability, and safety measures. No deficiencies were cited during this inspection visit, though advisory notes and technical assistance were provided.
Report Facts
Fire extinguishers: 14
Hospice waiver capacity: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Cole | Executive Director | Met with Licensing Program Analyst during inspection and received the report. |
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the inspection visit. |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 50
Deficiencies: 0
Oct 5, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including unlicensed staff administering insulin, lack of assistance with oxygen administration, inadequate staffing levels, failure to notify responsible parties of health changes, and unmet residents' hygiene care needs.
Findings
The investigation found that most allegations could not be substantiated due to lack of evidence or confirmation from staff and residents. Several staff denied or could not confirm the allegations, and residents with cognitive impairments were unable to confirm. The preponderance of evidence standard was not met, and the allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation addressed nine allegations including unlicensed insulin administration, failure to assist with oxygen, inadequate staffing, failure to notify families of health changes, and unmet hygiene needs. Interviews with staff and residents, review of medication administration records, and other documentation were conducted. The findings were unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 50
Census: 28
Missed calls: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Cole | Administrator | Facility administrator present during inspection |
| Troy Agard | Licensing Program Analyst | Investigator conducting the complaint investigation |
| Ulysses Coronel | Licensing Program Manager | Manager overseeing the complaint investigation |
| Kristin Beck | Administrator | Administrator who received the findings report |
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