Brookdale Santa Monica Gardens

On 3/5/25, at 10:00am, the department conducted an initial complaint visit to the facility and was greeted by Paloma Keitelman, Business Office Manager. The department explained the purpose of this visit is to gather information about the complaint, gather facility files, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The Department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R8) from 10:00am-2:00pm. The department received the following: Resident Roster (Dated: No Date), Staff Roster (Dated: 02/27/2025), Activities Calendar (Dated: January 2024-March 2025), and In-Service Trainings (Dated: 11/2024- 2/2025) from the facility. The investigation revealed the following: Allegation #1-Staff do not respond in a timely manner to residents' calls for assistance. Page 1 of 4 UnsubstantiatedRead the full finding— CDSS inspection report, March 5, 2025 · control 11-AS-20250227161639

On 09/11/24, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint investigation at the above facility to deliver findings. LPA met with Executive Director II Mia Nakanatzu. The investigation consisted of the following: During today’s visit, LPA conducted a second interview with one Caregiver and interviewed the Operations Specialist, Caregiver, and the Concierge. On 09/04/2024 Licensing Program Analysts (LPA) Regina Cloyd and Hollie Enriquez conducted a complaint investigation at the above facility to address the following allegations. LPAs met with Administrator Paloma Keitelman and explained the purpose of the visit. Executive Director II Mia Nakanatzu joined us later. The investigation consisted of the following: During today’s visit, LPAs interviewed residents and staff, reviewed the register of residents, personnel reports (LIC 500), accounting documents, maintenance documents and two resident records. Due to insufficient time, the above allegation neededRead the full finding— CDSS inspection report, September 11, 2024 · control 11-AS-20240826155915

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 6/6/24. On 6/6/24 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA arrived and spoke to the Executive Director, Mia Nakamatzu and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 5/23/24, LPA Felisa Shirley conducted a review of Staff roster, Resident roster, and resident files. LPA Shirley conducted a tour of the facility for a health and safety check. LPA requested and received copies of Physicians report, emailed communications, dementia notice 4/25/23, and hospice notification, emails dated 1/2/24 and 5/10/24. The investigation revealed the following: Con’d on 9099-C UnsubstantiatedRead the full finding— CDSS inspection report, June 6, 2024 · control 11-AS-20240517084753

On 05/16/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced visit to the facility listed above to deliver findings for the above allegations. LPA met with Health and Wellness Director, Milca Osorio, and the purpose of today’s visit was explained. During a previous visit conducted on 11/30/23, LPA toured the facility and received copies of documents pertinent to the investigation. The documents received and reviewed were the Staff Roster, Resident Roster, resident Physicians Report, Needs and Service Plans, and recent training logs. LPA interviewed residents (R2-R6) and staff (S1-S5). The investigation revealed the following: SubstantiatedRead the full finding— CDSS inspection report, May 16, 2024 · control 11-AS-20231121145936

On 02/02/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegations. LPA met with Business Office Manager Ashley Fernandez and Executive Director Mia Nakamatzu (via zoom) and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation LPA interviewed 6 out of 60 residents and 5 staff which included the Executive Director, Business Manager, Resident Engagement Manager, MedTech, Concierge, and the Health and Wellness Director. LPA reviewed the register of residents, personnel reports (LIC 500), accounting documents, and resident records. Continue to LIC 9099-C. UnsubstantiatedRead the full finding— CDSS inspection report, February 2, 2024 · control 11-AS-20240129223753

On 02/01/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit to this facility. Upon arrival at the facility, LPA Dabuet was greeted by Business Manager Ashley Fernandez. Fernandez contacted Executive Director Mia Nakamatzu who was available through virtual communication. The purpose of the visit was provided to Nakamatzu to investigate the allegation mentioned above. The investigation consisted of the following: Interview conducted with the Executive Director, Wellness Director, and Licensed Vocational Nurse. Inquiry questions were relevant to the nature of the complaint. Record reviews of documents of staff and residents’ roster (R1's) ID/Emergency Information, Preplacement Appraisal, In-House Service Assessment, and other pertinent documents associated with this complaint. A tour of the facility was conducted. (Evaluation Report continues LIC 9099-C) UnsubstantiatedRead the full finding— CDSS inspection report, February 2, 2024 · control 11-AS-20240111081540

THIS REPORT SUPERSEDES THE REPORT DATED 08/2/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: SUBSTANTIATED Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Brookdale Santa Monica Gardens on 08/02/2023 and was greeted by Operations Director Dimple Kamdar (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. During this investigation, LPA Calderon interviewed A1, S1, R1-R7. This interview was conducted on 08/02/2023. On 08/02/2023 LPA Calderon requested copies of the following: Staff LIC500 and Resident rosters, needs and service, physician report, admission agreement, any incident reports for R1 and the monthly activities calendar for the facility. The investigation reveaRead the full finding— CDSS inspection report, January 25, 2024 · control 11-AS-20230726082709

On 01/24/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent complaint visit to the facility listed above. LPA met with Executive Director, Mia Nakamatzu, and the purpose of today's visit was explained. During today's visit LPA conducted a facility tour and interviewed Resident R2 and Staff S1 and S7. LPA visited the facility on 10/12/23 and toured the facility and received copies of documents pertinent to the investigation. The documents received and reviewed were the Staff Roster, Resident Roster, Admission Agreement for resident, Physicians Report, Needs and Service Plans, Additional Service Charges, list of residents receiving oxygen, Theft and Loss Policy, and Resident Theft and Loss Log. On 11/30/23 LPA toured the facility and interviewed Staff (S2-S5) and Resident (R1-R5) The investigation revealed the following: Continued on LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, January 24, 2024 · control 11-AS-20231005145936

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Brookdale Santa Monica Gardens on 08/02/2023 and was greeted by Operations Director Dimple Kamdar (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. During this investigation, LPA Calderon interviewed A1, S1, R1-R7. This interview was conducted on 08/02/2023. On 08/02/2023 LPA Calderon requested copies of the following: Staff LIC500 and Resident rosters, needs and service, physician report, admission agreement, any incident reports for R1 and the monthly activities calendar for the facility. The investigation revealed the following: SubstantiatedRead the full finding— CDSS inspection report, August 2, 2023 · control 11-AS-20230726082709

On 01/31/24 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced visit to deliver this amended document and was met by Mia Nakamatzu, Executive Director. On 07/25/23, LPA conducted an unannounced, subsequent, complaint visit to the facility. LPA was met by Dimple Kamdar (DK), Operations Specialist, and later by Callie Michael (CM), District Director of Clinical Services, who were informed that this visit was conducted to investigate the allegations listed above, previously initiated on 07/24/23. On 07/24/23, LPA conducted a tour of the facility and observed no urgent issues. LPA requested facility documentation and reviewed the documents provided. LPA interviewed 5 (five) residents and 4 (four) staff. On 07/25/23, LPA requested further facility documentation and reviewed the documents provided. LPA interviewed two (2) residents and two (2) staff. Report continues, see LIC9099C. SubstantiatedRead the full finding— CDSS inspection report, July 25, 2023 · control 11-AS-20230719084523