Brookdale Santa Monica Gardens

Allegation investigated: Staff increased the resident’s fees without providing the required prior notice. Staff falsified the resident's records.

On 08/19/26, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegations. LPA met with the Executive Director Amanda Monroy. Investigation consisted of the following: On 08/18/26, the Department obtained Personnel Record, Register of Residents, and Residents #1 - #6 Records. LPA interviewed Staff #1 – 5, Residents #2 - #6, and Witness #1. LPA left a voicemail for Witness #3. On 08/19/26, LPA interviewed Staff #1, #6 and Witnesses #2, #4 - #5. Investigation revealed the following: Allegation: Staff increased the resident’s fees without providing the required prior notice. It is alleged Resident #1 (R1) received an updated plan of care and the bathroom assistance fees (increased from $262 to $918) were retroactive to April 2026. Continue to LIC9099-C. Unsubstantiated Record review revealed the following: R1’s Admission Agreement (07/22/21) revealed the community will provide (60) days written notice of any change in the rates for Basic Services, Personal Services, Select Services, Therapeutic Services or any other fees listed in this agreement. Additionally, we may offer or require a change in the Personal Service Plan when we determine additional services are requested or required. When such a change in services occurs and alters your personal service plan, the associated fees as referenced in Exhibit A and detailed in Exhibit Z, will be charged to you immediately after written notice of change in services is provided. Review of Exhibit Z (04/28/26) revealed the new charge ($918) is based on bathroom assistance that includes pulling up and down pants, handling toilet paper, wiping, changing protective undergarments and getting onto and off of toilet. Review of Assessment Summary (04/28/26) revealed the price was effective on 04/28/26. Interviews revealed the following: Interview with the Executive Director (S1) indicated S1 and the Health & Wellness Director (S6) met with R1 on 04/28/26 and provided R1 with the assessment summary and updated personal service plan. On 07/01/26, a second meeting was held and R1 indicated R1 wanted to attempt to meet R1’s own toileting needs. A two-week trial was provided. On 07/05/26, R1 emailed S1 indicating R1 could not complete toileting needs. S1 and S6 indicated caregivers have been providing bathroom assistance since 04/28/26. S6 indicated the assessment summary and personal service plan was provided on 04/28/26. S1 indicated R1 is not being charged the maximum amount for the bathroom services R1 receives. S1 indicated R1 was also provided with a $500 discount. Four out of four witnesses (W1 – W2, W4 – W5), responsible parties, indicated the invoice is accurate and there has been no retroactive charges. Regarding the allegation, “Staff increased the resident’s fees without providing the required prior notice,” based on record review and interviews, the preponderance of evidence standard has NOT been met, therefore the above allegation(s) is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff falsified the resident's records. It is alleged Resident #1 (R1) has not had a change of condition since admission but was presented with an updated plan of care with increased fees. Record review revealed the following: R1's Physician’s Report (2021) revealed R1 does not have bladder or bowel impairment and R1 is able to care for own toileting needs. Continue to LIC9099-C. R1’s Personal Service Plans (08/21, 11/21, 02/22) revealed R1 needs help in the bathroom. R1’s Personal Service Plan (2023) revealed R1 needs help in the bathroom and is incontinent of bladder. A caregiver will continue to assist resident with completing toileting tasks. R1 has no bowel nor bladder incontinence but uses incontinence products per preference. R1's Physician’s Report (2024) revealed R1 has bladder impairment (frequently) and is unable to meet toileting needs. R1’s Personal Service Plan (10/2024) revealed R1 needs assist with washing up (includes showering) after accidents, changing clothes, laundering soiled clothes and linens. R1 is incontinent of bladder. Personal Service Plan (04/2025) revealed R1 does not require bathroom assistance. R1 is incontinent of bladder. Personal Service Plan (10/2025) revealed R1 is to be reminded to change protective undergarments as needed. R1 is incontinent of bladder. R1’s Medical Assessment (2026) revealed R1 is bladder incontinence. Personal Service Plan (2026) revealed R1 needs help in the bathroom and is incontinent of bladder. Interviews revealed the following: Interview with the Executive Director (S1) indicated R1 has a history of refusing services but still receiving the care. On 04/28/26, S1 and the Health & Wellness Director (S6) met with R1 to provide an updated personal service plan. On 07/01/26, a second meeting was held and R1 indicated R1 did not need bathroom assistance but needed staff to wheel R1 into the bathroom and ensure all bathroom items were reachable. The facility gave R1 two weeks to complete the bathroom tasks but R1 still needed the care services. During the trial, S1 learned that the caregivers were still assisting R1 with incontinent care in the bed at night and in the mornings plus changing the bed linen. On 07/05/26, R1 indicated that the bathroom tasks were too much. Five out of five staff interviews (S1, S2, S4, S5, S6) indicated R1 receives toileting assistance. S5 indicated R1 has always needed more care. S6 indicated R1 really needs the maximum bathroom assistance. Five out of five resident interviews (R2 – R6) indicated they receive toileting assistance. Four out of four witnesses (W1 – W2, W4 – W5), responsible parties, indicated the plan of care is accurate. Regarding the allegation, “Staff falsified the resident's records, ” based on record review and interviews, the preponderance of evidence standard has NOT been met, therefore the above allegation(s) is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. An exit interview was conducted, and a hard copy of this report was provided to the Executive Director Amanda Monroy.the state’s words, verbatim · CDSS document, Aug 19, 2026 · control 11-AS-20260812105005

Type of visit: Required - 1 Year

On 07/23/26, Licensing Program Analysts (LPAs) Regina Cloyd and Antonine Richard conducted an unannounced annual visit using the CARE Inspection Tool. LPAs met with Staff and explained the purpose of today’s visit. The facility is licensed to serve one hundred twenty-eight (128) non-ambulatory residents. The facility has a hospice waiver for ten (10) residents. The facility does not currently have any residents receiving hospice care services. Annual fees are current. The physical plant consists of the following: ninety-two (92) resident rooms with attached bathrooms. There is a dining area, kitchen, beauty salon, garage, library, activity room, gym, front garden with two outdoor covered areas in with tables and chairs. The second through fourth floors have laundry rooms. Stairwell one has an evacuation chair and stairwell two has two evacuation chairs. Staff accompanied LPA Cloyd inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the facility were clear of hazards. Continue to LIC809-C. Resident bedrooms (105, 219, 329, 391, 404, and 419) had bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew, a non-skid mat was in place, and water temperature measured between 115.5 – 120.0 degrees Fahrenheit. Pull cords and resident pendants were tested on each floor and operational. Common areas were clean and clear of hazards. Doorways were free of obstructions. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives were kept in a secured kitchen. Toxins are locked in a storage closet. First aid kit was available. Fire extinguishers, last serviced in February 2026, were observed on each floor. A fire drill was conducted on 07/21/26. Santa Monica Fire Department conducted a fire inspection on 10/16/25. Six staff records were reviewed; six out of six staff records had the required criminal record clearances or criminal record exemptions. Eight resident records were reviewed; eight out of eight resident records had medical assessments and pre-appraisal or reappraisals. Three residents’ medication was reviewed. An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Office Business Manager Paloma Keitelman.the state’s words, verbatim · CDSS document, Jul 23, 2026

Type of visit: Required - 1 Year

On 5/1/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct a annual required inspection visit. LPA Allen met with Richard Pacheco- Maintenance Director who was informed of the purpose of the visit. The facility is an RCFE licensed for 128 non-ambulatory residents and there is an approved hospice waiver for 10. The facility is a four story structure located in a residential neighborhood. There are currently 56 residents residing in the facility. The physical plant consists of the following: ninety-two (92) resident rooms with attached bathrooms. There is a dining area, kitchen, garage, library, activity room, gym, front garden with two outdoor covered areas in with tables and chairs. At 9:50 AM - 11:22 AM LPA toured the physical plant with Richard Pacheco- Maintenance Director. There were no bodies of water or obstructions on the premises. LPA inspected a total of seven (7) bedrooms and seven (7) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. During the inspection Amanda Monroy-Administrator arrived and continued with assisting with the inspection. The bathrooms were in good condition and operational. The water temperature ranged from 105°F to 118. °F, and the bedroom temperatures ranged from 72°F to 78°F the facility appeared to be clean, sanitary, and appropriately furnished. LPA observed cleaning supplies / toxins stored in the house keeping closet inaccessible to residents. The kitchen was inspected, and there was a 5 day supply of perishable food items and a 7 day of non-perishable food items which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 4/30/2025. At 11:35 AM LPA also reviewed seven (7) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings which were all current with the exception of three (3) staff files reviewed did not have the required first aid/CPR certifications up to date. Training will be conducted on 5/2/2025. At 12:45 PM, LPA reviewed six (6) resident files for admission agreements, updated physician reports, and needs and services plans which were up to date. LPA also conducted a random audit of 6 residents medication administration records (MARS) which appeared that medications are being administered as prescribed by their physicians. Based on the observations made during today’s visit, a Technical Advisory was issued for not having 3 of the 6 staff members first aid/CPR certifications up to date. An exit interview was conducted, and this report was discussed and provided Amanda Monroy- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 1, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff do not respond in a timely manner to residents' calls for assistance. Staff do not ensure that residents are provided with planned daily activities. Staff do not maintain a facility activity calendar.

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 Unsubstantiated The details of the complaint alleged that the staff does not respond promptly to the residents call button. It is alleged that residents must wait up to one hour for assistance when they push the call button for assistance. On 3/5/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R8) regarding the allegation. Staff (S1-S4) denied the allegation that the Staff do not respond in a timely manner to residents' calls for assistance. Staff (S1-S4) stated that they do respond in a timely manner when residents ask for assistance. All staff stated that the average wait time for assistance is 15 minutes or less. The Department interviewed residents (R1-R8) about the allegation and 5 of 8 residents that were interviewed denied the allegation that Staff do not respond in a timely manner to residents' calls for assistance. The majority of the residents interviewed (5 of 8) stated that the staff does respond in a timely manner if they need assistance. They state on average it takes about 15 minutes or less to get help and are satisfied with the services provided. The Department reviewed the staff roster (Dated: 02/27/2025) and observed that there is a sufficient number of staff to meet the needs of the residents. Additionally, the department reviewed the In-Service Trainings (Dated: 11/2024- 2/2025) and observed that the staff had the required trainings in personal rights of residents. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not respond in a timely manner to residents' calls for assistance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #2- Staff do not ensure that residents are provided with planned daily activities. The details of the complaint alleged that the facility, for the past two months, is not ensuring that the residents have planned activities because there is not an activities director. On 3/5/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R8) regarding the allegation. Staff (S1-S4) denied the allegation that the Staff do not ensure that residents are provided with planned daily activities. All staff (S1-S4) stated that the facility does have daily activities for the residents to participate in, in the absence of a current activities’ director. S1 stated the facility is in the process of hiring a new activities director, and have two candidates in mind, and they are awaiting a final decision from the in-coming executive director. Page 2 of LIC9099-C The Department interviewed residents (R1-R8) about the allegation and 7 of 8 residents that were interviewed denied the allegation that Staff do not ensure that residents are provided with planned daily activities. The residents that were interviewed stated that the facility does have planned activities each day for the residents to participate in. The department reviewed the activities calendars (Dated: January 2024-March 2025) and observed that the facility has planned activities for the residents each day. Some of the activities include morning and afternoon exercise classes, bridge games, Mardi Gras celebration, shopping trips, silk scarf painting, women’s club meetings, St. Monica’s Legion of Mary Communion Service, jewelry making, mosaics arts and crafts, and a host of other activities for each day of the week. Additionally, the department reviewed the In-Service Trainings (Dated: 11/2024- 2/2025) and observed that the staff has trainings in inviting, assisting, and encouraging residents to participate in activities offered by the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not ensure that residents are provided with planned daily activities. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #3- Staff do not maintain a facility activities calendar. The details of the complaint alleged that the facility does not have a current activity calendar because there is not a current activities director. On 3/5/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R8) regarding the allegation. Staff (S1-S4) denied the allegation that the Staff do not maintain a facility activities calendar. All staff (S1-S4) stated that the facility does have an activities calendar and it is in the lobby of the facility on the wall. Additionally, they state that there are hand fliers with all the activities for each month on the table below the wall mounted calendar, so that residents can take it with them to have as a reminder. The Department interviewed residents (R1-R8) about the allegation and 7 of 8 residents that were interviewed denied the allegation that Staff do not maintain a facility activities calendar. The majority of residents that were interviewed (7 of 8) stated that the facility does have an activities calendar and they are aware of the activities provided by the facility. Page 3 of LIC 9099-C The Department reviewed the Activities Calendar (Dated: March 2025) and observed that the facility does in fact have planned activities for the residents to participate in each day of the month. On todays visit the department observed that the residents were participating in the Exercise B-Fit located in the activities room. Additionally, the department observed that there is a planned lunch outing, current events discussion, and a Happy Hour performance by a band later in the evening. Based on interviews, observations, and records reviewed, there is insufficient evidence to support the allegation that the Staff do not maintain a facility activities calendar. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued. An exit interview was conducted with Paloma Keitelman, Business Office Manager, and a hard copy of this Complaint Investigation Report was provided. Page 4 of LIC9099-Cthe state’s words, verbatim · CDSS document, Mar 5, 2025 · control 11-AS-20250227161639

Allegation investigated: The facility did not provide comfortable accommodations to residents in care. The facility did not provide quality food. The facility did not provide the correct refund amount.

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 needed further investigation. A copy of that report was reviewed and left with the Executive Director II Mia Nakanatzu. Continue to LIC9099-C Unsubstantiated Regarding the allegation "The facility did not provide comfortable accommodations to residents in care," it is being alleged that complaints about daytime noise (toilet pipelines) repairs to unit #201 were ignored. It is also being alleged that complaints about nighttime noise by caregiver services on the third floor (above Resident 1 (R1) and Resident 2’s (R2) room) were ignored. Four (4) out of eight (8) resident interviews, not including R1 and R2, indicated that they lived at the facility between August-September 2023. Three (3) out of four (4) residents who lived in the facility between August-September 2023 recall the pipe repair work causing some degree of noise that was at times a little annoying but not bothersome to require filing a complaint. Of the residents who recalled the construction noise, all three (3) indicated that the facility warned the residents of the repair work, and the work did not go into the night to disturb sleep. One (1) out of four (4) residents who lived in the facility between August-September 2023 did not recall the pipe repair work nor any construction causing some degree of noise. Two out of three staff members who were at the facility during the construction indicated that they did not receive any resident complaints concerning noise. Record reviews indicate that an email was sent from the facility’s Operations Specialist to R1 and R2’s daughter stating, “let me know if there is anything we can do to convince him to stay”. Phone interview with the Operations Specialist indicated that R1 and R2 was offered temporary relocation within the facility but could not guarantee complete silence since they lived in a community. Operations Specialist declined R1’s request to be relocated to a hotel. Regarding the allegation "The facility did not provide comfortable accommodations to residents in care,” based on interviews and record review, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation Regarding the allegation "the facility did not provide quality food,” it is being alleged that Styrofoam containers were used to serve hot meals during the facility repairs caused gout and resulted in Resident 1 (R1) being hospitalized on 09/21/23 for eleven days and in rehabilitation for four weeks. Record review reveals that R1’s admission agreement was executive on 08/14/23. It also reveals that R1’s previous Health Care Center Order Summary (07/27/23), addendum for additional personalization (07/31/23), physician’s report (08/10/23), admission record (08/17/23), and personal service plan (08/17/23) references a gout diagnosis. Continue to LIC9099-C. Four (4) out of eight (8) residents interviewed lived at the facility between August and September 2023. Three (3) out of four (4) residents who lived at the facility between August and September 2023 reported that there was a time that the kitchen may have used Styrofoam dishware for a short period during the pipe repair, but it did not impact the normal food quality. Eight (8) out of eight (8) residents interviewed reported that the food is usually on regular dishware but may be occasionally on Styrofoam, depending on the food and where the resident will dine. All eight (8) out of eight (8) residents reported that the normal food quality and choices were unaffected by when kitchen staff served meals in Styrofoam dishware. Eight (8) out of eight (8) residents reported that the food was good. Interview with the Chef indicated that cold lunches were served for lunch and hot boxes was used to keep hot meals warm during repairs. Also, the Chef indicated that the dining hall was only closed for about a week in the middle of August 2023. Finally, the Chef indicated that each resident has a microwave and refrigerator in his/her room. Interview with two Sous Chef indicated that no complaints were received concerning the temperature of the hot meals. Interview with the Executive Director II indicated that staff follows the Physician’s Diet Order. Record review reveals that R1 was on a regular diet with thin liquids dated 08/10/23. Regarding the allegation “the facility did not provide quality food," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation Regarding the allegation “the facility did not provide the correct refund amount,” it is being alleged that Resident #1 (R1) paid $3,853.00 and Resident #2 (R2) paid $3,043.00 for August services. It is being alleged that the amount was corrected the following month but the facility never reimbursed $810.00 to R1. Record review reveals that the additional funds remained on R1’s account. Interview with the Executive Director II indicated that a refund was not promised but that the money would remain on the account. Record review reveals that the additional charges were applied to the credit. The additional charges are associated with R1’s contract agreement: Terms and Termination in Section IV(B), Community Fee Rates in Section III(A)(3), and Addendum to the Residency Agreement Permanent Basic Service Rate Discount – Automatic Withdrawal. Regarding the allegation “the facility did not provide the correct refund amount," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was reviewed and provided to the Executive Director II Mia Nakanatzu.the state’s words, verbatim · CDSS document, Sep 11, 2024 · control 11-AS-20240826155915

Type of visit: Required - 1 Year

On 06/26/2024, Licensing Program Analyst (LPA) David España conducted an unannounced annual required visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA met with staff and explained the purpose of today’s visit. LPA was granted entrance to the facility. The facility is an RCFE licensed for one-hundred and twenty-eight (128) non-ambulatory and also includes a hospice waiver for (10) ten. Currently, there are 57 residents residing in the facility, all are over the age of 59 or older. LPA was later joined on the visit by Facility Mia Nakamatzu. The facility is a four-story structure located in a residential neighborhood. It consists of the following: ninety-two (92) resident rooms with attached bathrooms, dining area, kitchen, garage, library, activity room, gym, front garden with two outdoor covered areas in which there are tables and chairs, and a back outdoor covered area in which there are also tables and chairs. LPA España and Mia Nakamatzu toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided was provided in residents rooms and storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. LIC809-C Continued LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage for area cleaning supplies, toxins, and sharps objects was observed and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Smoke detectors were observed in client rooms and are connected to the fire department. LPA reviewed Medication Administration Record (MAR) and observed it to be maintained in order and accurate. During the visit, LPA observed the facility's infection control practices. All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD. No deficiencies were cited during this inspection visit. An exit interview was conducted, and a hard copy of this report was provided to Mia Nakamatzu.the state’s words, verbatim · CDSS document, Jun 26, 2024

Allegation investigated: Staff do not maintain accurate records. Staff did not monitoring a resident's change in condition. Resident left in soiled diapers for extended periods of time. Staff are not allowing resident's responsible party to remove resident from facility

*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 Unsubstantiated Allegation: Staff do not maintain accurate records It has been reported that facility staff had no knowledge of a resident having dementia prior to 5/2024 as it was reported that a notice from UCLA was hand delivered in 2023 and was also emailed January 2024. Staff requested party to forward email of notice from UCLA that was allegedly sent to them 1/24, but notice was never received from the party and this party told Staff to check their emails for the notice. LPA observed an email dated 1/2/24 with attachments that did not contain any notice from UCLA Health. Notice for dementia was not received until 5/10/24. On 6/6/24 LPA observed an email dated 5/10/24 with attachments from UCLA Health re notification of dementia. It was also reported that facility staff did not have correct move out date for a resident. LPA observed a 30day notice dated 5/6/24, stating that resident will be out of the unit before 5/31/24. LPA observed an email dated 5/15/24 stating that the party will be changing moving date to next week, date TBD after meeting with attorney. On Friday 5/17/24, staff received email from the party stating that they have a crew coming next Sunday at 9am to remove resident’s items. The following Sunday’s date was 5/19/24, with no arrival of crew to collect resident’s belongings. Staff received another email from the party dated 5/20/24 stating that the MedCare transport will be coming Friday 5/24/24 at 10am. LPA interviewed staff S1-S6, LPA ask, does staff maintain accurate records. Of those interviewed, 5 out of 6 answered yes, and 1 staff that did not know. LPA interviewed residents R1 – R6, LPA ask, to your knowledge, does staff keep accurate records. Of those interviewed, 3 out of 6 answered yes and the other 3 did not know. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Con'd on 9099-C Allegation: Staff did not monitor a resident’s change in condition It is being reported that staff did not monitor residents change in condition, nor were family notified that resident had a change in condition. LPA learned that the resident was receiving home health through Remedy Home Health 11/2023. A new assessment was done and the resident went back on hospice services with Avila Hospice 1/4/24. Hospice staff never knew of family. Facility staff sent notice to CCLD regarding Hospice services 1/5/24. Staff notified, W1 about resident’s change in condition as W1 was the only contact person on record for emergencies. There was never any type of family contact with hospice services at all. The only family on record for emergency contact since admission was the resident’s son, who is now deceased. Facility staff could not update the party about residents medical condition as there was no POA on record nor a conservator. LPA interviewed staff S1-S6, LPA ask, does staff monitor residents for change in condition. Of those interviewed, 5 out of 6 answered yes, as 1 staff did not know. LPA interviewed residents R1 – R6, LPA ask, does staff monitor you for change of condition. Of those interviewed, 5 out of 6 answered yes, and 1 resident did not know. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Resident left in soiled diapers for extended periods of time It was reported that a resident was left in soiled diapers for long periods of time and other residents providing this resident with incontinent supplies. During interviews, Con'd on 9099-C LPA Shirley learned that residents are monitored and staff do frequent checks for residents with incontinence issues. This resident was also on Home Health services and then Hospice services in which both provided incontinence products to residents that are receiving services. Per S6, resident was not receiving incontinence products from other residents. Borrowing from other residents is not allowed. LPA interviewed staff S1-S6, LPA ask, are residents left in soiled diapers for extended periods of time. Of those interviewed, 4 out of 6 answered no as 2 staff did not know. LPA interviewed residents R1 – R6, LPA ask, have you ever been left in your diaper for an extended amount of time. Of those interviewed, 5 out of 6 answered no and 1 resident said yes. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated Allegation: Staff are not allowing resident’s responsible party to remove resident from facility It is being reported that family found another facility for the resident as the resident does not have the resources to stay at this facility. LPA Shirley learned through interviews that this resident does not want to leave this facility and has been vocal about it. S1 stated that she will honor the request for this resident to be relocated if the resident chooses to leave this facility without any refusal or struggle. Upon LPAs return to Brookdale, LPA learned that the resident left with no problems or resistance. LPA interviewed staff S1-S6, LPA ask, does staff allow resident’s responsible party to remove residents from this facility. Con'd 9099-C Of those interviewed, 4 out of 6 answered yes and 2 staff did not know. LPA interviewed residents R1 – R6, LPA ask, is staff not allowing your responsible party to remove you from this facility. Of those interviewed, 3 out of 6 answered, yes and 3 did not know. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of the LIC 9099 was provided to Executive Director, Mia Nakamatzu.the state’s words, verbatim · CDSS document, Jun 6, 2024 · control 11-AS-20240517084753

Allegation investigated: Facility's signal system did not produce an auditory signal loud enough to summon staff. Lack of supervision

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: Substantiated Allegation: Facility signal system did not produce an auditory signal loud enough to summon staff. It is alleged Resident R1 was not feeling well in the middle of the night and pressed the medical alert button, but nobody came. R1 then called the front desk, and nobody answered the phone. During an interview with R1’s Responsible Party (W1) stated facility staff left them a voicemail stating the battery was low in R1’s pendant. Additionally, W1 stated when they brought R1 back from the hospital the following afternoon the facility’s phone system was still down. During interviews with Staff (S1 and S2), two (2) out of two (2) stated there was an issue with the phones on December 12, 2023, and that the phone system has gone down in the past. S1 stated there has been a new procedure implemented for when the phone system goes down and for the medical alert pendant to inform them when batteries are low on a resident’s pendant. During interviews with Residents (R1-R6) two (2) out of six (6) stated there has been times when they press their pendant for assistance and had to wait an extended period of time before a caregiver arrived and they received care. R6 stated there was a time they had to wait three (3) hours before assistance came. R1 stated that having to wait for assistance commonly occurs in the evenings and nights. During interviews with staff (S1-S7) seven (7) out of seven (7) stated they receive training annually regarding the medical alert pendants and had a training regarding the new procedures implemented regarding low batteries in pendants and the telephones when down. During the course of the investigation, LPA was able to find evidence to support the allegation. 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. Allegation: Lack of supervision. It is alleged that a resident fell in the night and waited for staff to help them till the morning when their breakfast was delivered. During interviews with Staff (S1-S7) seven (7) out of seven (7) stated rounds are to be done every two (2) hours per shift. Additionally, S2 stated if a resident is a fall risk or has recently returned from the hospital rounds are done hourly to check on that resident. During an interview with S3 stated there are some residents who prefer not to be checked on in the evenings. S3 marked the Resident Roster indicating which Residents do not want to be checked during the Noc shift. Upon review of that list, LPA observed R1 was not indicated on that list. During file review of Resident R1, LPA observed on the Physicians Report R1 needs medical supervision for fall precautions and on the Assessment Summary it is noted R1 has fallen in the past twelve months. During interviews with Residents (R1-R6), three (3) out of six (6) stated Staff come and check on them during the day. Additionally, during an interview Resident R1 stated staff comes and checks on them a limited number of times during the day. LPA asked R1 if they had any falls recently, R1 stated they had a fall, but they were doing much better. During an interview with R1’s Responsible Party (W1) stated R1 fell during the night, pressed their medical alert pendent at 4am, and called the front desk for assistance and could not get assistance. W1 stated R1 was able to pull themselves off the floor and waited until their breakfast was brought to them around 8:30am. During the course of the investigation, LPA was able to find evidence to support the allegation. 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. Deficiencies are cited on the attached LIC9099-D. An exit interview was conducted with Health and Wellness Director, Milca Osorio, and a copy of this report and appeal rights was provided.the state’s words, verbatim · CDSS document, May 16, 2024 · control 11-AS-20231121145936

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1) · Plan of correction due date: May 30, 2024

87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or building shall have a signal system which shall: transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This regulation was not met, based on interviews, staff did not ensure resident’s alert pendant signaled to staff to summon them to provide assistance.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Administrator will ensure that resident pendants are charged and implement a plan for when pendants are not working or when the phones go down. Administrator will fax a copy of the plan and training logs to LPA. Att. LPA Gibbs (424)544-1016

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(e) · Plan of correction due date: May 30, 2024

1569.312 Basic Services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This regulation was not met, based on record review, and interviews the Administrator did not comply with this regulation and a fall risk resident R1 was not monitored through the night.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Administrator will conduct training for staff regarding conducting resident checks every 2-hours. Administrator will fax a copy of the staff sign-in for the training and any training material used. Att. LPA Gibbs (424)544-1016

Allegation investigated: Staff did not issue a refund.

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. Unsubstantiated The investigation revealed the following: Regarding the allegation "Staff did not issue a refund," Record reviews indicate that R1 and R2 was refunded their community fee according to the terms of the signed admission agreement. LPA observed on page 8 Section IV(B) states, You may terminate this Agreement upon thirty (30) days written notice to the facility. Termination occurs on the later of the end of the notice period or upon the removal of all of your personal belongings. Records reviews indicate that on 09/09/23, R1 submitted a written notice that R1 and R2 would move out of the facility on 09/13/23 and the medical bed would be removed on 09/14/23. LPA observed on page 6 Section III(A)(3) states, “If you complete a pre-admission appraisal (personal service assessment), five hundred dollars ($500) of the Community Fee becomes non-refundable, with the remainder of the Community Fee (“Refundable Amount”) subject to the following refund rules: (2) Once you enter the Community, if this Agreement terminates and you leave for any reason within the second month of residency, you are entitled to a refund of sixty percent (60%) of the Refundable Amount. Record reviews indicate that R1 and R2 received a refunded community fee on 10/06/23 and the credit was applied to the account balance. Interviews with the Executive Director and Business Manager indicate that Accounting mailed the remaining credit balance on 10/10/23. Interviews conducted indicated the following: Five out of five staff interviews disagreed with the allegations. One staff member was unavailable for the interview. Five out of six residents interviewed disagreed with the allegations. Regarding the allegation "Staff did not issue a refund,” the investigation revealed that a refund was issued. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was reviewed and provided to the Business Manager Ashley Fernandez.the state’s words, verbatim · CDSS document, Feb 2, 2024 · control 11-AS-20240129223753

Allegation investigated: Facility staff did not provide resident's representative with a statement itemizing all separate charges incurred.

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) Unsubstantiated INVESTIGATION REVEALED FOLLOWING: Allegation: Facility staff did not provide resident's representative with a statement itemizing all separate charges incurred. The details of the complaint reported the facility failed to provide resident #1 (R1) representative with itemized charges. The complainant reported (R1) was provided with a rate increase of $2,000.00 for an increase of care and did not provide the itemized charges. The complainant claimed that (R1) was contracted for $6094.00 for basic services based on (R1's) needs and services were agreed upon under the contract. The complainant claimed there was no agreement for the additional rate increase of $2,000.00. A request for additional information and supporting documents, the complainant was unable to provide. Resident #1 (R1's) residency began effective 05/30/23. A Residency Agreement between Brookdale Santa Monica Gardens and the legal representative for (R1) (dated on 05/26/23) was signed on 05/28/23. Included in the Residency Agreement are the terms and conditions of the agreement. It specified the Services and Accommodations. The Basic Services included: Accommodation, Dining Service, Utility Services, Housekeeping Service, Laundry and Linen Service, Activities Program, Transportation, Staffing 24-hr daily, Observation and Consultation, and Assistance with Access to Outside Services. The Personal Services (outlined in Exhibit Z of the Residency Agreement contract). In Exhibit Z these services are additional charges not included within the Basic Services and it is based on (R1's) medical assessment and needs and service plan defined as follows: Medications (assistance with medications), Chronic Condition Management (specific care and/monitoring by nurse or care associate for more complex insulin), Nutrition (assistance with planning, preparing or/monitoring nutritional needs), and Service Coordinator. Medication (assistance with scheduling medical/dental or lab appointments). The Residency Agreement included the itemized charges listed on Exhibit A with the following: Community Fee before Move-In of $5000.00, Basic Service Rate of $6505.00, and Personal Service Rate of $1211.00 (itemized in Exhibit Z). In the Addendum to the Residency Agreement Personal Service Rate Maximum Pricing, is outlined under the Personal Service Plan Service Rate Maximum of $7965.00. Under an Addendum to the Residency Agreement Permanent Basic Service Rate Discount, "The Community agrees to discount the Basic Service Rate of $6505.00 by $1626.00 (discount)". According to the Residency Agreement agreed between (R1's) legal representative and Brookdale Santa Monica Gardens (dated: 05/26/23), it indicated itemized charges of the Basic Service Rate $6505.00, Basic Services Discount $1626.00, and Personal Service Rate (Evaluation Report continues LIC 9099-C) (medication management $1101.00, chronic condition management $1982.00, nutrition $330, and service coordinator $110.00) for a total of $8402.00. A signature of acknowledgement from (R1's) legal representative (dated: 05/28/24) validated this is a legal contract, and a legal copy was provided to (R1's) legal representative. On 01/17/24 between 10:00 am - 01:41 pm, the Department interviewed (2) out (2) staff #1-#2 (S1-S2) and stated were both unaware if a request for a statement itemizing all separate charges incurred was ever requested for (R1). (S1-S2), however, provided the Department documentation records for (R1) with the following Residency Agreement (dated: 05/26/23), Assessment Summary (dated: 05/23/23 - 06/20/23, Account History Report (dated: 08/06/23 and 01/17/24), Account Balance Activity (dated: 06/16/23-07/14/23-09/14/23-11-16-23, and 11/30/23) and an internal written communication reference to (R1) were issued. On 02/02/24 between 11:54 am - 12:12 pm, the Department interviewed staff #3 (S3). (S3) identified in the complaint as the business manager is not the business manager, and (S3's) role is the Clinical Specialist/License Vocational Nurse and had nothing to do with residents' charges. (S3's) role was to assist with residents' care with more complex programs. (S3) claimed there were numerous conversations related to (R1's) personal service but does not recall a request for a statement itemizing all separate charges incurred for (R1). (S3) disclosed the medical assessment was performed before (R1) moved in, and it remained the same throughout (R1's) residency at the facility. (S3) communicated that in no circumstances would additional fees for services would be charged without an agreement with the resident or the resident's legal representative. The Department obtained an internal progress note (dated: 08/10/23) of a discussion on a conference call on 08/09/23 with (R1's) legal representative, (S3), and with former Executive Director. The discussion related to (R1's) Care Plan and Medication Management and the Chronic Condition charges was disputed. There was no mention of a statement request for itemized charges. Based on the information provider, an inspection of the facility, observation, interviews, and analysis of records, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. An exit interview was conducted with Milca Osorio, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 2, 2024 · control 11-AS-20240111081540

Allegation investigated: Staff do not provide adequate activities for residents

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 revealed the following: Substantiated Regarding Allegation #1: Staff do not provide adequate activities for residents. The alleged staff did not provide adequate activities for residents in care. On 08/02/2023 LPA Calderon interviewed A1 for a complaint. A1 reported that S1 must work as facility driver and activities director and that this does affect residents’ activities. A1 reported that the facility does provide a monthly activities calendar but, due to staffing issues, most activities are not done. A1 relays that more interactive activities need to be offered to residents in care. On 08/02/2023 LPA Calderon interviewed S1 for complaint. S1 claimed that the facility lets go of the facility driver and S1 assistant. S1 expressed that S1 did not know if S1 had to drive residents, and this affected if S1 was able to give activities to residents. S1 stated that there are not enough staff to provide activities to residents in care. On 08/02/2023 LPA attempted to interview R1, but R1 left the facility for the day. On 08/02/2023 LPA Calderon interviewed R2-R8 for complaint. R7 relays that R7 loves the activities provided by staff and has no issues. R2-R6 and R8 stated that the activity director is the best S1 can do and there are not enough interactions with staff and activities that make the residents think. R2-R6 and R8 relay that the community calendar is not followed by staff and the administrator is aware of this situation. On 08/02/2023 LPA Calderon reviewed the community calendar with all residents and residents could not pick out what activities they loved to do; most activities were not attended. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation “staff do not provide adequate activities for residents” is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are cited on the attached LIC 9099D. An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Operations Director Dimple Kamdar (A1). Regarding Allegation #1: Staff prevent residents from having visitors during reasonable hours. The alleged staff prevent residents from having visitors during reasonable hours. On 08/02/2023 LPA Calderon interviewed A1 for complaint. A1 relays that the facility has an admission agreement which R1 signed. A1 relays that all visitors, guests, and family are welcome to visit. A1 relays that no visitor, guest, or family can stay over night and the facility does not discriminate against a resident with health issues. On 08/03/2023 LPA Calderon attempted to interview R1 for complaint, R1 left the facility for the day. On 08/02/2023 LPA Calderon interviewed R2-R8 for complaint. R2-R8 relays that no visitor, guest, or family can stay overnight, and all visitors, guest and family are welcome and R2-R8 have never had any issues. On 08/02/2023 LPA Calderon reviewed the residency agreement signed by R1 family on 05/28/2023. The agreement does not suggest a time a guest, visitor or family can arrive at the facility or leave the facility. Overnight guests are generally not permitted in a resident’s room. Based on evidence gathered from investigation there is insufficient evidence to prove that “staff prevent residents from having visitors during reasonable hours”, therefore the allegation is unsubstantiated. An exit interview was conducted and copy of the Complaint Report was provided to the Operations Director Dimple Kamdar (A1).the state’s words, verbatim · CDSS document, Jan 25, 2024 · control 11-AS-20230726082709

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a) · Plan of correction due date: Feb 2, 2024

87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement is not met as evidenced by: Based on interviews, observations and records the licensee failed to ensure that the facility has a active activity planner that all residents attend. This poses a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: The administrator will adhere to Title 22 Reg 87219(a) and provide a plan on how to address sufficient activities for the facility for residents in care. POC will be presented to the CCL by due date: 02/01/24 by email to LPA Calderon at: Jose.Calderon@dss.ca.govThe administrator will adhere to Title 22 Reg 87219(a) and provide a plan on how to address sufficient activities for the facility for residents in care. POC will be presented to the CCL by due date: 02/01/24 by email to LPA Calderon at: Jose.Calderon@dss.ca.gov

Allegation investigated: Staff failed to safeguard resident's personal property Resident is being financially abused at the facility.

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 Unsubstantiated Allegation: Staff failed to safeguard resident’s personal belongings. The allegation alleges that there has been theft of items. During interviews with Residents (R1-R6), four (4) out of six (6) stated they have had no items go missing, nor do they have any concerns regarding staff safeguarding their belongings. Resident R1 stated they have had some items go missing, some they were able to find, and others are gone. Additionally, R1 stated one of the missing items was explained by staff why the item was removed from their room, due to it being a health and safety issue. Resident R6 stated they have had a few items go missing such as clothing, but it is not something they are concerned about. During interviews with Staff (S1-S6) six (6) out of six (6) stated when a resident reports a missing item, staff will assist the resident in searching their room, common areas, and staff will check the laundry room. Staff S1 stated if the item is not found staff who were working at the time the item went missing will be questioned if they have seen it and the family will be notified. Additionally, S1 stated there has been times when they notified the families of the missing item, the family will inform them their resident had donated the item weeks ago or has gotten rid of it. During an interview with Staff S2 and S3, stated R1 had an item removed from their room while they were in the hospital due to it being a health and safety risk, and they informed R1 upon return to the facility. During review of the Resident Loss and Theft Log, LPA observed that some of the items that were reported missing by R1 were found in R1’s room. During review of residents Admission Agreement, LPA observed it states on page 12, number 9. “We make no representations or guarantees that we can prevent the loss of personal item…We will not be responsible for the loss of such items unless such loss is due to our Continued on LIC9099-C negligence or misconduct. We make no representations or guarantees that we can prevent theft or other criminal acts perpetrated by another resident or person; therefore, we recommend that valuables such as jewelry and large sums of money, not be kept at the community. If you choose to bring valuables, you do so at your own risk and we will not be held responsible for any theft or loss of such items, unless such loss is due to our negligence or misconduct or the negligent or misconduct of our associates.” Additionally, during file review of R1's file, LPA observed that R1's Safeguard of Property/Valuable was signed but they did not fill it out. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Resident is being financially abused at the facility. The allegation alleges the facility is overcharging for essentials such as oxygen, caregiving, electric bed and wheelchair equipment and transportation services. During interviews with Residents (R1-R6), four (4) out of six (6) stated they have not been overcharged for services and have no concerns regarding the charge for services they receive. Resident R1 stated they were charged for services they did not receive while they were in the hospital. Resident R6 stated they feel the facility charges too much for services. During interviews with Staff S1 and S2, two out of two stated when a resident is admitted to the facility an assessment of the resident is conducted and the services they need or want are discussed. The residents are able to select or deny the services they require or want. Resident’s bills are based Continued on LIC9099-C on the service they select. Additionally, Staff S1 and S2 stated that even if the Resident is in the hospital that rent and service fees are still charged per the Admission Agreement. During file review, LPA reviewed the Resident’s Admission Agreement that states on page 7, C. Absence, Fees During Absence. “If you are absent from the Community for any reason, such as, for a hospitalization, vacation, temporary nursing home care or rehabilitation, the Residency Agreement will remain effective and you will be charged the full Monthly Service Rate.” During an interview with Resident R1, they stated they wanted a new mattress and when they called the company to order just a mattress the company stated they do not sell just the mattress and they would need to purchase the entire bed (hospital bed). LPA reviewed the receipt for the purchase and the company is not associated with the facility. During an interview with Resident R1, they stated they got a new wheelchair that their insurance covered, and the new wheelchair broke they ordered a new one and they were charged for it. LPA reviewed the receipt for the wheelchair and the company is not associated with the facility. During file review of Residents R1 and R2’s Admission Agreement, LPA reviewed the services selected and reviewed their monthly billing statement and upon review LPA observed the costs and amounts to be consistent. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated. During today's visit LPA did not observe or cite any deficiencies. An exit interview was conducted with Executive Director, Mia Nakamatzu, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 24, 2024 · control 11-AS-20231005145936