BROOKDALE SANTA MONICA GARDENS

Official classification

Type B

Official code

87303(i)(1)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: May 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.312(e)

Regulation authority

HSC

What the official deficiency says

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.

Official 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

Deadline recorded: May 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Feb 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator will hire more staff and generate a new atcivities calendar with impute from residents in care.

Deadline recorded: Aug 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition..residents in privately operated residential care facilities for the elderly (RCFE) shall have all of the following personal rights: (4) To care..and services..meet..needs ..delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This deficiency has not been met as evidenced by: S3 has changed position as of 04/27/23, requiring S4 to stand-in which limits S4 duty.

Official plan of correction

LPA and S1 have agreed that the facility will have a new Class B driver on, or prior to, the POC due date (08/29/23) in order to support the residents to be able to enjoy their lunch, shopping and sightseeing outings. This will also allow S4 to better focus on their duty. S1 will keep LPA informed as to the next hire date(s) of the future transportation, caregiving, wellness, and executive director departments' staff(ing) via email at Mario.Leon@DSS.CA.GOV.

Deadline recorded: Aug 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(7)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ..residents in privately operated RCFE shall have..following personal rights: (7) To fully participate in..communications regarding care and services provided, according to Health and Safety Code 1569.80..in this planning. The licensee shall provide necessary information and support to..residents..maximum extent possible,.. enabled to make informed decisions..choices. This has not been met as evidenced by: Facility has been lacking a stable Executive Director since 04/29/23

Official plan of correction

LPA and S1 have agreed that the facility will continue to improve their management skills in order to better provide detailed information regarding various questions that will arise from the residential community. The facility will ensure that all new staff will remain proactive in communications with the current and future resident community.

Deadline recorded: Jul 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2023 Plan of Correction The licensee will submit a plan of correction and documentation that an administrator has met the certications specified in Section 87406 to LPA Antonine.Rchard@dss.ca.gov via email. (323) 516-4092