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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800837
Report Date: 05/04/2021
Date Signed: 05/04/2021 03:22:03 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:
05/04/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Stephania Radu, AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lyndia Sager conducted a case management visit to deliver final investigation findings telephonically with Stephania 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 deficiencies:

LPA requested Hospice documents related to Resident #1 (R1). The Administrator was not able to provide all the hospice documents related to R1. LPA had to obtain some of the missing information from the Hospice Agency.

LPA reviewed the Physician’s Reports dated 05/23/2019 and 06/23/2020 – both state R1 had a diagnosis of Dementia. Information obtained from the Hospice Agency states R1 was diagnosed with Dementia from 05/16/2018 through 01/27/2021. The facility Plan of Operation states that they will not accept or retain residents with a diagnosis of Dementia.

During staff interviews on 04/21/2021, LPA observed 5 staff who spoke only Spanish or needed a translator during the interview.

Deficiencies 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: 05/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 05/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2021
Section Cited

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87506 Resident Records
(b) Each resident’s record shall contain at least the following information:
(13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services.
This requirement is not met as evidenced by:
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Based on interviews and documents reviewed, the facility did not ensure R1’s file was complete with all necessary hospice paperwork which posed a potential health and safety risk to residents in care.
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Type B
05/11/2021
Section Cited

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87208 Plan of Operation
(b)(3) Statement of admission policies and procedures regarding acceptance of persons for services. This requirement is not met as evidenced by:
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Based on interviews and documents reviewed, the licensee retained R1 with a diagnosis of Dementia when the plan of operation specifically states it will not accept or retain residents diagnosed with Dementia, 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: 05/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 05/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2021
Section Cited

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87411 Personnel Requirements - General
(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by:
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Based on staff interviews conducted on 04/21/2021, LPA observed 5 staff who spoke only Spanish or needed a translator during the interview, 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: 05/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3