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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204758
Report Date: 09/29/2023
Date Signed: 10/12/2023 10:49:42 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/27/2023 and conducted by Evaluator Jeremiah Randle
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230627152651
FACILITY NAME:BROOKDALE OCEAN HOUSEFACILITY NUMBER:
198204758
ADMINISTRATOR:PARK, THOMASFACILITY TYPE:
740
ADDRESS:2107 OCEAN AVETELEPHONE:
(310) 399-3227
CITY:SANTA MONICASTATE: CAZIP CODE:
90405
CAPACITY:150CENSUS: 78DATE:
09/29/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Assoc. Executive Director Jayden Bettencourt. TIME COMPLETED:
02:41 PM
ALLEGATION(S):
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Staff financially abused resident.
INVESTIGATION FINDINGS:
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On 10/12/23, Licenising Program Analyst (LPA), Wendy Gibbs conducted an unnanounced visit to amend the report. LPA met with Executive Director Jayden Bennencourt and explained the purpose of today's visit.

On 09/29/2023 at 10:00 a.m. Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced visit to deliver the findings of the complaint allegation: Staff stole resident's money while in care. LPA identified himself and discussed the purpose of the visit and the elements of the allegation(s). with Assoc. Executive Director Jayden Bettencourt.

The Investigation Consisted Of The Following
On 06/28/23 Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced 24-hour visit to Brookdale Ocean House. LPA was met by Matan Burstyn Executive Director. The Purpose of the visit was explained to investigate the allegation " Personal Rights” and conduct a health and safety check on residents in care.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 11-AS-20230627152651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BROOKDALE OCEAN HOUSE
FACILITY NUMBER: 198204758
VISIT DATE: 09/29/2023
NARRATIVE
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Cont from Pg 1

All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained throughout the facility. LPA observed the facility to be operational and in good repair. Residents were currently sitting in the movie screening room, activity room, and gaming rooms. Residents did not show any signs of distress or abuse. LPA requested pertinent documents pertaining to the investigation. The following documents were gathered: Resident Roster, Staff Roster, Copy of entire resident file for (R1) including Admissions Agreement, Needs and Services, physicians report. LPA requested facility staff schedules and other pertinent documentation such as staff files.

On 6/28/2023 LPA referred this assignment case to the Investigations Branch (IB) of the Department of Social Services to conduct the interviews of the above allegation. Investigator Heidy Bendana (IB) interviewed the following individuals. Witness (W1), Victim (V1), Administrator (A1), Staff (S1-S2) and Residents (R1-R4).

The Investigation Revealed The Following.

Allegation: Staff financially abused resident.

On 7/25/2023, at approximately 0754 hours, Investigator Heidy Bendana, interviewed Witness #1 via telephone. Witness #1 indicates W1 assist V1 with accounting due to V1 medical diagnosis but V1 is responsible for V1’s checkbook. W1 indicated during a review of V1 taxes W1 noticed on V1 bank account online a $9,000 check cleared made out to cash. W1 reported this to V1 and V1 denied writing a check for cash. On 7/25/2023, at approximately 1058 hours, Investigator Heidy Bendana, interviewed Victim #1. V1 had been a resident at Brookdale Ocean House. V1 informed Investigator that $9,000 was withdrawn from V1 First Citizen’s bank account and $1,000 from Bank of America account. V1 reported V1 checkbooks were stolen from Brookdale Ocean House. V1 confirmed S1 gave V1 a $8000 cashier’s check and said it solved the problem. V1 stated V1 asked S1 where’s the rest because the total amount stolen was $10,000.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 11-AS-20230627152651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BROOKDALE OCEAN HOUSE
FACILITY NUMBER: 198204758
VISIT DATE: 09/29/2023
NARRATIVE
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Cont from Page 2

On 7/27/2023, at approximately 0946 hours, I, Investigator Heidy Bendana, interviewed Matan Burstyn at her place of employment. Matan stated Victim #1 lived at the facility before she started her employment with the facility. Matan stated she was informed S1 stole $10,000 dollars from V1. On 08/2/2023, at approximately 0924 hours, Investigator Heidy Bendana, interviewed S3 via FaceTime. S1 stated V1 gave S1 a check for $1,000 & $9,000. S1 confirmed S1 cashed both checks at S1 bank. S1 stated later S1 attempted to return the money and V1 told S1 to keep some money therefore S1 only gave V1 a Cashiers check for $8,000. IB investigator interviewed Staff #2 and S2 corroborated the allegation. IB investigator interviewed Residents #1-4 and 4 of the 4 residents did not have any knowledge of the allegation.

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(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of the LIC 9099 and 9099D and Appeal Rights was provided to Assoc. Executive Director Jayden Bettencourt ,

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20230627152651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE OCEAN HOUSE
FACILITY NUMBER: 198204758
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
CCR
87468.1(a)(e)
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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 personal rights:(3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money....This requirement is not met as evidenced by:
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Administrator will provide LPA, per fax, staff meeting sign in sheet, regarding review of resident's personal rights - specifically abuse, or other actions of a punitive nature, such as withholding residents’ money, by 10/09/23. LPA fax number (323) 981-1781
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Based on interview and records review, the licensee failed to ensure resident's personal rights due to staff person #1 mis- appropriating residents money from Resident V1 personal bank account. This poses a personal rights risk to residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4