Welbrook Senior Living Santa Monica

Type of visit: Office

On 05/26/2026, at 10:00am, an office meeting was held to discuss Complaint 11-AS-20250113093823. Present at the meeting were Eva Alvarez, Licensing Program Manager (LPM), Wendy Gibbs, Licensing Program Analyst (LPA), Mr. David Cole, Vice President of Operations, and Catalina Cole, Administrator. During the meeting, the LPM reviewed the details of the Complaint. On April 10, 2025, the Department substantiated an allegation of Resident sustained a serious injury while in care. At this time the Department is considering an enhanced civil penalty, pursuant to Health and Safety Code Section 1569.49(f). The Department is reviewing the complaint for an enhanced civil penalty for serious bodily injury pursuant to H&S 1569.49(f). The total amount for the civil penalty totals $10,000 for Serious Bodily Injury. An exit interview was conducted with, Mr. David Cole, Vice President of Operations, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 26, 2026

Allegation investigated: Staff did not adequately address resident's fall risk. Resident sustained injuries due to staff neglect. Staff left resident unsupervised for an extended period of time.

On May 20, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted a subsequent unannounced complaint visit. David Cole, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegations mentioned above. The investigation included interviews, inspection of the facility, and a collection of documents. A review of Personnel Report LIC 500 (dated 12/23/25 and 04/08/26), Register of Faciltiy Residents Residential Care Facilities for the Elderly LIC 9020 (dated 01/30/26 and 04/07/26), Annual and Continuing Education Training and Relias Training, (R1's) Admission Agreement (dated 06/30/25), Unusual Incident Report LIC 624 (dated 11/19/25 and 01/26/26), Physicians Report LIC 602A (dated 06/14/23), Durabale Power of Attorney (dated 08/01/216), and other pertinent records associated with this complaint. Interviews conducted with Resident#2 through #6 (R2-R6) and Staff #1 through Staff #6 (S1-S6). (Evaluation Report continues on LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not adequately address resident's fall risk. Allegation #2: Resident sustained injuries due to staff neglect. The complaint alleges that the staff did not adequately address Resident #1 (R1’s) fall risk. It is reported that (R1) had unwitnessed fall in November 2025 and which resulted in right eye injury leading to blindness. After the incident (R1) received short-term nursing care post discharge from Ronald Reagan UCLA Medical Center and returned to the facility fearing that (R1) may fall again. No further details regarding these matters were provided. Resident #1 (R1) was admitted to Welbrook Santa Monica on June 30, 2023, in accordance with the facility’s Admission Agreement (dated 06/30/23). (R1) voluntarily terminated their residency on February 21, 2026, at which time personal belongings were removed from the premises. From November 19 to November 23, 2025, (R1) received medical attention at Ronald Reagan UCLA Medical Center for a visual injury, necessitating transportation to the hospital for appropriate treatment. On February 5, 2026, and May 7, 2026, between 11:34 AM and 01:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Six (6) out of the six (6) staff members could not validate both claims. The initial assessments conducted by (S1-S2) indicated that (R1) did not have a prior history of falls from (R1’s) primary care physician. The Physician’s Report LIC 602A (dated 06/14/23) did not identify (R1) as a fall risk. However, the facility’s Senior Living Functional Assessment (ISP) (dated 05/07/26) noted that (R1) had experienced a few falls and that a fall prevention plan was implemented. It was confirmed by (S1-S2) that, despite initial assessment noting a history of falls, (R1) did not experience any falls during care at the facility. (S1-S6) confirmed that before (R1) being admitted to Welbrook Senior Living, (R1) had a medical assessment that revealed visual impairment related to glaucoma. On November 19, 2025, an incident involving (R1) was reported as having an unwitnessed fall. At 4:50 AM, a staff member discovered (R1) sitting on the bed, holding (R1’s) eye. Upon examination, a skin tear or cut near (R1’s) eye was identified. The area was promptly cleaned, and emergency services were called; (R1) and were subsequently transported to the hospital. (S1) confirmed that a thorough inspection of (R1’s) room revealed no blood on the floor or any evidence of a fall. It appears likely that (R1) unintentionally rolled over in bed and hit (R1’s) face against the sharp corner of the night stand, resulting in the eye injury. (Evaluation Report continues LIC 9099-C) The following day the facility took preventive measures and implemented soft foam corner guards and placed them on nightstand corners for safety measures. The injury did not result in blindness in accordance with (R1’s) and UCLA Health medical records (dated 11/23/25) and (R1’s) primary physician’s office visit (dated 12/05/25). According to (S2), (R1), after being hospitalized and subsequently receiving assistance from a private caregiver affiliated with UCLA Health for a full 30 days. Additionally, (S1-S2) provided (R1) with a staff-on-standby caregiver during the night shift at no extra cost. This caregiver was responsible for monitoring and escorting (R1), even though a medical assessment confirmed that one-on-one care was not necessary following the hospital stay. Throughout this period, (R1) received checks every two hours or as needed. On May 7, 2026, between 11:16 AM and 12:00 PM, the Department interviewed resident members identified as Resident #2 through Resident #6 (R2-R6). Five (5) out of five (5) residents could not support these claims. (R2-R6) confirmed that they have not experienced any falls and have not sustained injuries from falls. They expressed appreciation for the staff, noting that they are watchful in monitoring all residents and will escort them to prevent falls while under their care. The Department was unable to conduct an interview with Resident #1 (R1) due to (R1's) unavailability. Furthermore, the Department was unable to reach Witness #1 (W1) as the calls went unanswered. A review of (R1’s) Physician’s Report LIC 602A (dated 06/14/23), Preplacement Appraisal Information LIC 603 (dated 06/30/23), Senior Living Functional Assessment (ISP) (dated 06/29/23), Fall Risk Assessment (dated 11/24/25) revealed (R1) was assessed before admittance at the facility with a visual impairment and had a fall plan in place. Further review of UCL A Health Medical Records (dated 11/23/25), Physician’s Office Visit (dated 12/05/25), Unusual Incident Report LIC 624 (dated 11/19/25), and Fall Risk Assessment (dated 11/24/25) revealed there is no proof to suggest that an impact from a fall and eye injury resulted in blindness. Further review of Preplacement Appraisal Information LIC 603 (dated 06/30/23) revealed visual impairment related to glaucoma. On February 5, 2026, between 8:12 AM and 12:47 PM, the Department inspected (R1's) room. During the inspection, it was noted that the room contained minimal furnishings, including a mattress and box spring without a bed frame, a nightstand, a dresser, a club chair, an over-bed table, and a television. The nightstands were equipped with furniture corner guards for safety. Additionally, the shower was fitted with grab bars, a shower seat, non-skid flooring, and an adjustable commode chair with handles. (Evaluation Report continues LIC 9099-C) Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Allegation #3: Staff left resident unsupervised for an extended period of time. It is alleged that staff member Resident #1 (R1) was left unsupervised for an extended period. On January 24, 2026, it was reported that R1 was found on the floor in liquid waste, which had allegedly occurred the previous day. Concerns have been raised about staffing levels. No further details regarding this matter were provided. On February 5, 2026, and May 7, 2026, between 11:34 AM and 01:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Six (6) out of the six (6) staff members could not support this claim. (S1) expressed on January 22, 2026, (R1) has shown increasing agitation towards staff over the past few days, prompting them to notify the family representative Witness #1 (W1) about the significant change in (R1’s) condition. Witness #1 (W1) was urged to consider taking (R1) to the hospital. While waiting, staff closely monitored (R1) to ensure safety, but (R1) continued to display aggressive behavior, including making a mess of (R1’s) bodily fluids. When (W1) arrived and found it challenging to manage (R1’s) behavior, the facility called 9-1-1; however, ultimately (W1) declined EMS assistance and chose to transport (R1) to the hospital. (W1) also attempted to clean (R1) before the hospital visit but had limited success. (S1) since the hospitalization, reported (R1) never returned back to the facility. (S1-S5) confirmed that there is no staffing shortage and that adequate staffing is maintained for all shifts. For the morning shift, which is from 6:30 AM to 3:00 PM, the regular staffing consists of eight care staff members, two licensed vocational nurses, one medication technician, and two activity directors. The evening shift, from 2:30 PM to 11:00 PM, includes seven care staff members, one licensed vocational nurse, and one medication technician. The night shift, from 10:30 PM to 7:00 AM, has five care staff members. (S1-S2) reported that the facility handles call-outs by offering extra hours to existing staff to cover shifts. In the event of a staffing crisis, the facility employs personnel from 1Heart Caregivers Services. (S1-S5) stated that (R1) never experienced staff shortages. (R1) was monitored every two hours or as needed. Additionally, (S2) reported that Resident #1 (R1) received assistance from a private care staff member provided by Santa Monica UCLA following (R1's) hospitalization in November 2025. This assistance lasted for 30 days. (S1-S2) also offered (R1) a stand-by care staff member to monitor and escort (R1) at no extra charge, even though (R1) was medically assessed as not needing one-on-one care after hospitalization. (Evaluation Report continues LIC 9099-C) On May 7, 2026, between 11:16 AM and 12:00 PM, the Department interviewed residents identified as Resident #2 through Resident #6 (R2-R6). Five (5) out of the five (5) resident members stated they could not support the claim. (R2-R6) reported no issues with the care and supervision provided by staff and stated they had never been left unsupervised for an extended period. The Department was unable to conduct an interview with Resident #1 (R1) due to (R1’s) unavailability. Furthermore, the Department was unable to reach Witness #1 (W1) as the calls went unanswered. The Department reviewed the facility’s Personnel Report LIC 500 (dated 12/23/25 and 04/08/26) confirmed the staffing numbers of personnel for each shift as stated by (S1-S5). Further review of Annual and Continuing Education Training materials and Relias Training verified the mandatory staff training implementation by the facility. A review of Unusual Incident Report LIC 624 (dated 11/19/25 and 01/26/25). Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. An exit interview was conducted with David Cole, and copies of the reports were provided.the state’s words, verbatim · CDSS document, May 20, 2026 · control 11-AS-20260130085139

Allegation investigated: Staff did not ensure that resident's room was kept in a sanitary condition. Licensee does not ensure that staff are adequately trained.

On May 07, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted a subsequent unannounced complaint visit. David Cole, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegations mentioned above. The investigation included interviews, inspection of the facility, and a collection of documents. A review of Personnel Report LIC 500 (dated 12/23/25 and 04/08/26), Register of Faciltiy Residents Residential Care Facilities for the Elderly LIC 9020 (dated 01/30/26 and 04/07/26), Annual and Continuing Education Training and Relias Training, (R1's) Admission Agreement (dated 06/30/25), Unusual Incident Report LIC 624 (dated 11/19/25 and 01/26/26), Physicians Report LIC 602A (dated 06/14/23) and other pertinent records associated with this complaint. Interviews conducted with Resident#2 through #6 (R2-R6) and Staff #1 through Staff #6 (S1-S6). (Evaluation Report continues on LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #4: Staff did not ensure that resident's room was kept in a sanitary condition. The complaint alleges that the staff did not ensure Resident #1 (R1’s) room was kept in sanitary condition. According to reports (R1’s) room is kept clean and not in sanitary condition. No further detailed information is provided regarding this matter. Resident #1 (R1) was admitted at Welbrook Santa Monica on June 30, 2023, according to the facility’s Admission Agreement (dated 06/20/23). (R1) voluntarily terminated residency on February 21, 2026, when (R1’s) personal belongings were removed. On February 5, 2026, and May 7, 2026, between 11:34 AM and 01:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Six (6) out of the six (6) staff members could not validate this claim. All staff members denied the claim and stated that they have never left (R1’s) room in an unkempt, unclean, or unsanitized condition. (S1 and S6) emphasized that the residents’ rooms receive daily cleaning by housekeeping, with caregivers on hand to ensure that the rooms remain tidy and well maintained. On May 7, 2026, between 11:16 AM and 12:00 PM, the Department interviewed resident members identified as Resident #2 through Resident #6 (R2-R6). Five (5) out of five (5) residents could not support this claim. (R2-R6) confirmed that the rooms and common areas are consistently maintained in a clean, orderly, and sanitized condition daily. Resident #1 (R1) was unavailable for an interview. On February 5, 2026, the Department inspected the residents’ rooms 105, 107, 108, 218, 226, and room 225 (R1’s room) and observed that all rooms were presentable, orderly, clean, and sanitized. A review of (R1’s) Admission Agreement, (dated 06/30/26), indicated the following under Section 2 as part of the basic service, Housekeeping Services: Services for your room include vacuuming, dusting, bathroom cleaning, and changing personal bed linens as needed and within reason. This agreement was signed by (R1’s) Power of Attorney on June 30, 2025. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099-C) Allegation #5: Licensee does not ensure that staff are adequately trained. The complaint alleges that the staff are not adequately trained for their roles. It has been reported that Welbrook is facing staff shortages, and its management lacks the necessary training in memory care. Concerns have been raised about the well-being and safety of Resident #1 (R1) at this facility. No further detailed information is available regarding this matter. On February 5, 2026, and May 7, 2026, between 11:34 AM and 01:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Six (6) out of the six (6) staff members could not support this claim. All staff members denied the claim and stated that they had completed the mandatory Annual and Continuing Education Training. The training courses covered a variety of subjects, including Neurocognitive Disorders (NCD), Hospice care, and Residential Care Facilities for the Elderly. In total, staff members completed between 32 and 40 hours of training, which included in-person classroom sessions, hands-on shadow training, and Relias training, a comprehensive online learning management system for a continuing education platform designed for healthcare and senior care professionals. (S1-S5) verified that there is no staffing shortage and there’s adequate staffing for all shifts. (S2-S5) reported that regular staffing consists of for morning shift 6:30 AM – 3:00 PM with (8) care staff, (2) licensed vocational nurses (1) medication technician and (2) activity directors. The evening shift 2:30 PM – 11:00 PM consists of (7) care staff, (1) licensed vocation nurse and (1) medication technician. The nocturnal shift from 10:30 PM to 7:00 AM consists of (5) care staff. (S1-S2) reported the facility handles call outs by offering staff extra hours to cover shifts. In the event of staffing crises, the facility employs personnel staff from 1Heart Caregivers Services. Additionally, it was reported by (S2) that Resident #1 (R1) received assistance from a private care staff member provided by Santa Monica UCLA following (R1's) hospitalization in November 2025. This assistance lasted for 30 days. (S1-S2) also offered (R1) the option of a stand-by care staff member to monitor and escort (R1) at no extra charge, despite (R1) being medically assessed as not needing 1-on-1 care after hospitalization. On May 7, 2026, between 11:16 AM and 12:00 PM, the Department interviewed resident members identified as Resident #2 through Resident #6 (R2-R6). Five (5) out of five (5) residents could not corroborate this claim. (R2-R6) presumed the staff were well trained, as they received adequate care and supervision. (R2-R6) expressed that they had not experienced staff shortages, as there were always staff available to attend to their needs. Resident #1 (R1) was unavailable for an interview. (Evaluation Report continues LIC 9099-C) The Department reviewed the facility’s Personnel Report LIC 500 (dated 12/23/25 and 04/08/26) confirmed the staffing numbers of personnel for each shift as stated by (S1-S5). Further review of Annual and Continuing Education Training materials and Relias Training verified the mandatory staff training implementation by the facility. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. No deficiencies were cited. An exit interview was conducted with DAVID COLE, and copies of the reports were provided.the state’s words, verbatim · CDSS document, May 7, 2026 · control 11-AS-20260130085139

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff do not meet incontinent care needs of residents Staff do not ensure hazardous items are inaccessible to residents Staff force residents to eat Staff do not ensure that residents are provided meals

On 04/07/2026, the department conducted an initial complaint visit to the facility and was greeted by David Cole, Vice President of Operations. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff and residents, 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-R6). The department received the following documents: Staff Roster (Dated: 03/12/2026), Resident Roster (Dated: 01/30/2026), ID/Emergency Information (Dated: 06/30/2023, 09/18/2023, 05/2/2025, 12/29/2022, 07/19/2023, 09/25/2021), Pre-Placement Appraisal (Dated: 06/30/202310/02/2023, 05/24/2025, 12/31/2022, 07/19/2023, 06/08/2021), Physician’s Report (Dated: 08/24/2021, 07/18/2023, 12/29/2022, 04/08/2025, 04/19/2023, 06/28/2023), Resident Service Plan (Dated: 08/24/2021, 07/25/2023, 01/12/2023, 06/11/2025, 09/12/2023, 07/04/2023) and Welbrook Weekly Menu (Dated: 04/06/2026-04/12/2026) from the facility. Report Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #1- Staff do not meet incontinent care needs of residents. The details of the complaint alleged that the facility staff do not meet the incontinent needs of its residents. It was reported that staff often double brief a resident and have them go many hours without being changed. On 4/7/2026, from 10:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not meet incontinent care needs of residents. All staff stated that they do meet the incontinent care needs of their residents. Staff stated that the residents are checked on every two hours throughout the day to see if they need to be changed. Staff also stated that some residents may need to be checked on more often, it all depends on their care plan and the needs of a particular resident. Staff further stated that it is not a practice to double brief a resident in the facility. The department interviewed residents (R1-R6) about the allegation and 6 of 6 residents that were interviewed stated that their incontinent needs are being met and that staff does assist them promptly as needed throughout the day. The department reviewed the Physician’s Report (Dated: 08/24/2021, 07/18/2023, 12/29/2022, 04/08/2025, 04/19/2023, 06/28/2023) and Resident Service Plan (Dated: 08/24/2021, 07/25/2023, 01/12/2023, 06/11/2025, 09/12/2023, 07/04/2023) and observed that there is a plan in place to assist those residents who are incontinent. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not meet incontinent care needs of residents. 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 hazardous items are inaccessible to residents. The details of the complaint alleged that the facility staff does not ensure hazardous items are inaccessible to residents. It was reported that the facility staff leave items that are hazardous to residents like shampoos, lotions, and ointments in reach of the residents causing a safety risk. On 04/7/2026, from 10:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not ensure hazardous items are inaccessible to residents. All staff stated that the facility ensures that any items that are hazardous or unsafe for residents who have behavior issues are always in a locked cabinet. Staff further states that they have not observed any hazardous or unsafe items that were immediately accessible to residents nor has anyone complained about it. Report Continued On LIC9099-C The department interviewed residents (R1-R6) about the allegation and 6 of 6 residents that were interviewed stated that the facility staff does ensure that they are living in a safe environment; and they have not witnessed any hazardous or unsafe items in the facility or in their rooms. Based on interviews, there is insufficient evidence to support the allegation that Staff do not ensure hazardous items are inaccessible to residents. 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 force residents to eat. The details of the complaint alleged that the facility staff force residents to eat. It was reported that staff force feed residents when they do not want to eat or give them Ensure instead of feeding them due to a lack of patience. On 04/7/2026, from 10:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. 4 of 4 staff denied the allegation that Staff force residents to eat. All staff stated that they do not force any resident to eat when they do not want to eat. They also stated that force feeding a resident a meal is never acceptable under any circumstances. The department interviewed residents (R1-R6) about the allegation and 6 of 6 residents that were interviewed stated that the staff has never forced them to eat a meal. They also stated that they have never witnessed a staff member force feeding any other resident in the facility. Based on interviews, there is insufficient evidence to support the allegation that Staff force residents to eat. 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 #4-Staff do not ensure that residents are provided meals. The details of the complaint alleged that the facility staff do not ensure that the residents are provided with adequate meals. On 04/7/2026, from 10:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not ensure that residents are provided meals. All staff stated that the facility provides meals three times per day. They stated that residents are served breakfast, lunch, dinner, and snacks throughout the day. Staff stated that any resident who may have missed a meal, that meal is set aside for later if they choose to eat it, but no one is ever denied food in the facility. The department interviewed residents (R1-R6) about the allegation and 6 of 6 residents that were interviewed stated that the facility serves three meals per day, plus snacks. They all stated that they never went without a meal because the staff did not provide it for them. Report Continued On LIC9099-C The department reviewed the Welbrook Weekly Menu (Dated: 04/06/2026-04/12/2026) and observed that the facility does provide breakfast, lunch, and dinner for the residents in care. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not ensure that residents are provided meals. 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 for this complaint investigation. An exit interview was conducted with David Cole, Vice President of Operations, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 11-AS-20260330142946

Allegation investigated: Staff restrained a resident

On 12/23/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver the findings for the alleged allegation. LPA met with Administrator David Cole, and he was explained the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with staff members Staff 1-7 (S1-S7) and Residents 1-6 (R1-R6) and observations of staff interactions with the residents in care. The investigation revealed the following: Allegation: Staff restrained a resident Continued.... Unsubstantiated On December 23, 2025, at 1:05 PM, Licensing Program Analyst (LPA) Allen conducted interviews with seven (7) staff members 1-7 (S1–S7) and 7 out of 7 staff members stated that they have never seen or heard of any staff member, past or present, restraining a resident in any manner. LPA also interviewed six (6) residents 1-6 (R1–R6) and 6 out of 6 residents reported that they have never been restrained by any staff member in any way. During the visit, LPA observed staff interacting with residents in a respectful manner. LPA observed that residents were not handled roughly or restrained by staff at any time during the observation. Based on the interviews and observations gathered during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, during which this report was discussed and provided to David Cole- Administrator at the conclusion of the visit, along with appeal rights.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 11-AS-20251217093653

Type of visit: Required - 1 Year

On 09/19/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conducted a annual inspection. Upon arrival LPA met with the Wellness Director- Chhandita Panday who was informed of the purpose of today’s visit. Administrator Catalina Cole arrived at 9:00 AM and she was also informed of the purpose of todays visit. The facility is licensed to care for (50) non-ambulatory residents ages 60 and over and approved for(15) hospice waivers. The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (50) resident bedrooms, (50) resident bathrooms and (4) public restrooms, dining room, laundry room, business offices,kitchen,outdoor patio,salon,medication room,and an employee lounge. The facility temperature ranged from 73 - 79 degrees F. At 9:00AM, LPA Allen and Catalina toured the physical plant. There were no bodies of water on the premises. At 9:15AM, LPA Allen and Catalina inspected bedrooms #101, #110, #216, #218 and #232 the bathrooms were operational with water temperature measured at 105.2 – 107.9 degrees F. The bedrooms have the required furniture such as beds and bedding supplies which appeared to be in good condition,there is adequate lighting provided, and storage for the resident's personal belongings Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and inaccessible to residents. Continued.... The kitchen was inspected, and there was a 5-day supply of perishable and a 7-day supply of non-perishable food items available, which were adequately maintained and stored there was also a menu available for review. The fire extinguishers, carbon monoxide detectors and smoke detectors were fully charged and operable. The last fire drill was 9/2/2025. At 11:45 AM, LPA Allen reviewed four (4) residents’ files for admission agreements, updated physician reports, and needs and services plan which appeared to be up to date. LPA Allen reviewed four (4) staff files to verify First Aid/CPR certification, criminal record clearance, and health screenings. All reviewed items appeared to be current and up to date. However, during the review of staff files for S1, S2, S3, and S4, no annual training records were available for review and not in compliance with Title 22, Division 6, Chapter 8. Based on the observations made during today’s visit, a deficiency was cited. An exit interview was conducted where this report LIC809, 809-C and LIC809D was discussed and provided to Catalina Cole- Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Sep 19, 2025

Allegation investigated: Resident sustained a serious injury while in care. Resident left facility unsupervised.

On April 3, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted a subsequent complaint visit to continue investigation and to deliver findings regarding the above allegations. LPA Lee met with David Cole Executive Director and explained the reason for the visit. The investigation consisted of the following: On January 17, 2025, during initial 10-day visit, LPA Lee and David Cole toured the facility inside and out and tested the upstairs alarm system and delayed egress which was operational. LPA requested and reviewed, staff roster (dated 9/21/24), resident's roster (dated 12/30/24), Incident Reports (dated 12/19/23 and 2/2/24) Elopement Procedure, Preplacement Appraisal Information for R1 (dated 12/30/22), Physician's Report for Residential Care for the Elderly (RCFE) dated 12/29/22. LPA reviewed Admission Agreement (date signed 1/4/23). LPA Lee interviewed Executive Director/Administrator (A1), 7 residents (R2-R8), and 7 staff (S1- S7). Page 1 of 4 Substantiated On April 3, 2025, during subsequent visit, LPA Lee obtained a copy of elopement procedure training and sign in sheet. The training was conducted March 17-28, 2025. During the investigation, LPA conducted 5 additional staff interviews (S8-S12) via telephone and/or obtained written statements due to their shift schedule and availability at the time of LPA’s visit. The investigation revealed the following: Resident sustained a serious injury while in care The detail of the complaint alleges that on February 2, 2024 R1 sustained a fractured hip while eloping from facility. On 1/17/2025 between 8:30am and 9:40am, LPA interviewed Administrator David Cole (A1) who did not deny the allegation and informed LPA that he was aware of the incident and completed an Unusual Incident Report (UIR) when it occurred. A1 stated that all exit doors are delayed egress and equipped with a secondary alarm. Despite the alarms on the exit door, R1 was able to get out of the facility and subsequently found in the rear of building. On 01/17/2025, LPA reviewed ambulance transport document, which revealed that on 2/2/24 at 10:00pm R1 was seen by a passerby laying on ground in alleyway near facility. 911 was called, R1 reportedly complained of hip pain. Emergency services transported R1 to Ronald Reagan Medical Center. The review of R1's Emergency Department to Hospital admission/discharge documentation (MR #6530489) dated 2/2/24 revealed that R1 arrived via ambulance transport to ER and was subsequently admitted to hospital. R1’s diagnosis was Intertrochanteric Fracture, Osteoporotic Hip Fracture. R1 was treated and discharged on 2/10/2024. Page 2 of 4 Based on the information gathered, there is sufficient evidence to support the stated allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Resident left facility unsupervised The detail of the complaint alleges that on February 2, 2024 Welbrook Senior Living staff was not aware that R1 had left the facility until they were notified by the paramedics who responded to the call of a woman lying in an alleyway behind the facility. On 1/17/2025 between 8:30am and 9:40am, LPA interviewed Administrator David Cole (A1) who confirmed the allegation. On 0/17/2025, LPA interviewed 7 staff regarding the allegation and of those interviewed, 7 out of 7 stated that R1 did not elope on their shift but they were aware of the incident. 7 out of 7 stated that they are all training on the alarm system and the elopement protocol. Of the 5 additional staff interviewed, 4 out of 5 were on shift during R1’s elopement; 4 out of 5 stated they did not hear the alarm as they were downstairs preparing for a shift transition. On 4/3/25 during subsequent visit, A1 confirmed that the alarm can not be heard on first floor of the facility. Additionally, 4 out of 5 indicated that they are trained on the alarm system and the elopement protocol. On 1/17/25 LPA obtained/reviewed Unusual Incident Report (UIR) dated 2/3/24 explaining the incident which corroborated the allegation. Page 3 of 4 Based on the information gathered, there is sufficient evidence to support the stated allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 article 12 are being cited on the attached LIC 9099D. Exit interview conducted and copy of report given to David Cole, Executive Director. Page 4 of 4 Staff failed to report resident injury to responsible party On 1/17/2025, LPA obtained/reviewed the Unusual Incident Report(UIR) dated 2/3/24 sent by facility. The report indicated that the responsible party was contacted. On 1/17/2025 staff #6 indicated that she contacted responsible party to inform him of the incident. Based on the information gathered, there is insufficient evidence to support the stated allegation Although the allegations above 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 are UNSUBSTANTIATED No deficiencies were cited for the above allegations. Exit interview was conducted. A copy of this report was provided to David Cole, Executive Director.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 11-AS-20250113093823

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Apr 10, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following… (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by: Based on interviews and records review. Licensee did not ensure the safety of (R1) who wandered out of the facility, unsupervised by staff. R1 Sustained a serious injury during elopement from facility on 2/2/24.. This violation poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: The administrator to complete and submit a written plan to LPA ensuring the safety of all residents via email to Deborah.Lee@dss.ca.gov by POC due date 4/10/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(e)(7) · Plan of correction due date: Apr 10, 2025

87705 (e)(7) Care of Persons with Dementia (e) Licensees that use delayed egress devices on exterior doors... shall meet the following requirements…(7) Delayed egress devices shall not substitute for trained staff...to meet the care and supervision needs of all residents, including staff needed to escort residents who need supervision to leave the facility. This requirement was not met as evidenced by: Based on interviews, and record review staff were not on 2nd floor where R1 eloped from at time of incident and did not hear the alarm.This violation poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: Administrator agreed to ensure that there will always be staff on 2nd floor including during shift transition periods. The administrator to forward policy to LPA via email by POC due date 4/10/25.

Type of visit: Required - 1 Year

On 09/21/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Activities Director Maria Cox and Business Office Director Maria Schwartz. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (50) non-ambulatory elderly adults. The facility is approved for (15) hospice residents. The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (50) resident bedrooms, (50) resident bathrooms and (4) public restrooms, a dining room, a laundry room, business offices, an industrial kitchen, outdoor patio, a salon, a med room, and an employee lounge. LPA Dabuet and Schwartz toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #110, #102, #115, #113, #202, and #221. Bathrooms were operational with water temperature measured at 105.2 – 107.9 degrees F. A comfortable temperature was maintained in the facility at 73 - 79 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Evaluation Report continues LIC 809-C Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including Activities Calendar and Food Menu. LPA conducted an audit of resident #1-#5 (R1-R5) service files, and staff #1-#5 (S1-S5) personnel files were in order. The facility is current in CCLD annual fees. The administrator certificate for Cole Catalina 7022822740 is in pending renewal status. The facility has a Liability Insurance Certificate valid 11/24/23 through 11/24/24. The facility is current on CCLD annual license fees. DEFICIENCIES: Audit of staff roster and schedule revealed Staff #6 did not have Criminal Clearance Transfer Associated to this facility. Records indicated no LIC 9162 or appears on CDSS Guardian System. Staff #3, #4, and #5 all did not have current First Aid/CPR certificate on file. Staff #3 did not have a LIC 503 Health Screening on file Staff #3 did not have TB test results. Resident #2 and #4 diagnosed with Dementia did not have current medical assessment and reappraisal on file. Advisory - Technical Violation (see LIC 9102) According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 809-D). An exit interview conducted with the Maria Schwartz, and a copy of the report is provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *the state’s words, verbatim · CDSS document, Sep 21, 2024

Allegation investigated: Staff impose restrictions on resident’s visitors. Staff do not allow resident to receive phone calls.

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Welbrook Senior Living Santa Monica facility on 11/08/2023 and was greeted by Administrator David Cole (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. Investigation consisted of: LPA Calderon interviewed Administrator David Cole A1, S1, R1-R4. These interviews were conducted on 11/08/2023. On 11/08/2023 LPA Calderon obtained and reviewed the following: Copy of the court conservatorship (dated 09/26/2023) Physician Report (dated 10/27/2022), Copy of visiting policy (dated ##/##/####). Emails (dated 12/22/2022, 8/2/2023 and 10/24/2023). The investigation revealed the following: Unsubstantiated Regarding Allegation #1: Staff impose restrictions on residents’ visitors. This complaint alleged facility did not allow Reporting party access to R1. LPA Calderon conducted an interview with A1. A1 states that the reporting party has called R1 and made R1 agitated and mad. A1 states that the reporting party has never visited R1 at the facility and in general there are no restrictions for family or guests to visit R1. A1 states that A1 received an email from the conservator on 10/24/2023. The email from the conservator states to preclude reporting party from visiting R1. LPA Calderon conducted an interview with S1. S1 states that the staff has never prevented the reporting party from visiting R1 at the facility until the conservator precluded reporting party from visiting R1. LPA Calderon conducted an interview with R1. R1 states that R1 does not have any issues with reporting party visiting R1 at the facility but reporting party lives in Northern California. LPA Calderon conducted an interview with R2-R4. 3 out of 4 residents state that the facility has not stopped friends or family members visiting them. Reviewed email (dated 10/24/2023) from R1 conservator to A1 regarding reporting party visitations. The conservator has precluded reporting party from visiting R1. LPA Calderon conducted an interview with R1 conservator. The conservator states that facility staff has advised conservator that R1 has cried after speaking to reporting party and conservator has precluded reporting from visiting R1. Regarding Allegation #2 Staff do not allow residents to receive phone calls. This complaint alleged facility did not allow calls from RP to R1. LPA Calderon conducted an interview with A1. A1 states that the reporting party has called R1 and made R1 agitated and mad. A1 states that the reporting party has called R1 many times with no issues. A1 states that reporting would tell R1 that the conservator would steal R1 money. A1 states that R1 would repeat what was told to R1 and R1 would start to cry and get mad. A1 states in general there are no restrictions for family or guests to call R1. A1 states that A1 received an email from the conservator on 10/24/2023. The email from the conservator states to preclude reporting party from calling R1. LPA Calderon conducted an interview with S1. S1 states that S1 witness R1 speak to the reporting party and that R1 would repeat that the conservator is stealing R1 money. S1 states that S1 reviewed the email dated 10/24/2023 precluded reporting party from calling R1. LPA Calderon conducted an interview with R1. R1 states that R1 does not have any issues with reporting party calling R1 at the facility. R1 states that the reporting party would never hurt her but R1 forgets past conversations. LPA Calderon conducted an interview with R2-R4. 3 out of 4 residents state that the facility has not stopped friends or family members from calling. Reviewed email (dated 10/24/2023) from R1 conservator to A1 regarding reporting party calls. The conservator has precluded reporting party from calling R1. LPA Calderon conducted an interview with R1 conservator. Conservator states that facility staff has advised conservator that R1 has cried after speaking to reporting party and conservator has precluded reporting from calling R1. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “staff impose restrictions on residents’ visitors” “staff do not allow resident to receive phone calls” is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator David Cole (A1).the state’s words, verbatim · CDSS document, Nov 8, 2023 · control 11-AS-20231102134318

Type of visit: Required - 1 Year

On 10/4/2023, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection and met with David Cole, Administrator & Vice President of Operations. Facility is licensed to serve 50 residents and 15 hospice with dementia waiver. The Annual Licensing Fees are current. The facility consists of 2 floor levels, 50 resident bedrooms, 1 industrial kitchen, 1 dinning area, 1 outside patio, and common areas. The administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Resident bedrooms had the required furniture, 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 and a non-skid mat was in place, hot water temperature properly measured between 111.8 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. 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 and toxics were kept in locked storage cabinet. First Aid kit was available. Smoke detectors, carbon monoxide detectors, and fire extinguishers are tested annually. LPA observed that all bedrooms and hallways are equipped with a carbon monoxide and smoke detector. 5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions. 5 resident records were reviewed and, 5 out of 5 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. An exit interview was conducted, A copy of this report and appeal rights were discussed and left with the administrator.the state’s words, verbatim · CDSS document, Oct 4, 2023