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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800837
Report Date: 05/06/2021
Date Signed: 05/06/2021 03:12:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GARDEN COURT AT VILLA SANTA BARBARAFACILITY NUMBER:
425800837
ADMINISTRATOR:STEFANIA RADUFACILITY TYPE:
740
ADDRESS:227 E. ANAPAMU STREETTELEPHONE:
(805) 963-4428
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:126CENSUS: 62DATE:
05/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Stefania Radu, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lyndia Sager conducted a Case Management visit to deliver final investigation findings telephonically with Stefania Radu, Administrator, due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures.

During the course of an investigation regarding complaint #29-AS-20190813113112 allegations, LPA Sager observed the following deficiency that was inadvertently omitted on the Case Management Report issued 05/04/2021.

On Page 9 of the current resident and service agreement (revised January 15, 2015 version 1.1) for resident #1 (R1) states “the community’s plan of operation, which includes features specific to the provision of services related to Dementia or Alzheimer’s disease is available for review upon request”.



The plan of operation in the facility file states they are not a Dementia facility. The approved copy of the resident and services agreement dated 02/06/2006 page 6 states “not a Dementia facility”. This is part of the Plan of Operation approved by Community Care Licensing. There is no record that a revised admission agreement was submitted to Community Care Licensing for review and approval.

Deficiency issued on 809-D, telephonic exit interview was conducted with the Administrator, and a copy of the report was provided via email for signature. Appeal Rights emailed.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Lyndia SagerTELEPHONE: (805) 680-7683
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN COURT AT VILLA SANTA BARBARA
FACILITY NUMBER: 425800837
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2021
Section Cited

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87208 Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file.....Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval.
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This requirement is not met as evidenced by: Based on review of R1's admission agreement, the language has been revised 01/15/15 without first submitting to CCL for review and approval, which posed a potential health and safety 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.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Lyndia SagerTELEPHONE: (805) 680-7683
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2021
LIC809 (FAS) - (06/04)
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