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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425800837
Report Date: 05/25/2023
Date Signed: 05/25/2023 01:56:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/11/2021 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20210511080512
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:0CENSUS: 0DATE:
05/25/2023
UNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Rick Olds, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident sustained multiple falls.
Staff did not ensure Resident had access to meal(s).
Staff does not respond to resident's call button in a timely manner.
Staff did not accord privacy to Resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kontilis issued final findings for this investigation via certified mail, regular mail and email. The facility closed on 3/24/2023.
During the initial investigation visit on 5/18/2021 between 11:03 am and 4:15 pm, LPA conducted staff interviews, resident interviews, and reviewed relevant documents. LPA conducted a subsequent visit on 9/29/2021 from 1:30 pm to 3:30 pm to conduct additional interviews and obtain additional documents. LPA interviewed resident’s responsible party on 3/29/2023 and witnesses on 4/4/2023. LPA interviewed residents and staff on 5/2/2023 at 1:22 pm, 5/3/2023 from 10:13am to 2:50 pm, and 5/15/2023 at 9:30 am. LPA interviewed Director of Operations on 5/22/2023 at 3:11 pm.
On the allegation: Resident sustained multiple falls. It was alleged that R1’s call button was not answered timely, and as a result, R1 tried to use the restroom alone, resulting in falls.
R1’s physician’s report dated 1/9/2020 indicates R1 has a diagnosis of neurocognitive disease, cerebral atherosclerosis, osteoporosis, hypertension, diabetes, chronic kidney disease, a history of deep vein
Please continue to 9099-C, Pg 2.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
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 6
Control Number 29-AS-20210511080512
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/25/2023
NARRATIVE
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thrombosis, and mild cognitive impairment. The physician’s report indicates R1 does not have bowel or bladder impairment, uses a wheelchair and is unable to walk, is unable to bathe self, and needs assistance with toileting needs. The facility identified R1 as a fall risk when asked about residents who are a fall risk. R1’s assessment indicates they need “extensive” assistance with mobility/ambulation/escorting, and “requires hands on assistance by staff member.” The assessment indicates R1 can only walk 2-3 steps and requires total assistance, needs “total transfer assistance, lifting required,” and needs toileting assistance “extensive: resident requires toileting/incontinent checks during waking OR nighttime hours.”
R1’s responsible party (RP) was interviewed regarding the falls. RP stated they were aware of R1 falling a couple of times trying to go to the restroom on their own, because staff did not assist R1 even after they used their call button. LPA reviewed incidents reports for R1. LPA observed multiple incident reports for issues unrelated to falls. LPA observed an incident on 10/31/2020 where R1 was found on the floor by their bed. The incident stated the facility investigated the fall due to possible resident neglect. The facility filed an SOC 341 suspected abuse form on one of their staff, Staff 1 (S1), and informed the Ombudsman and police. LPA interviewed Director of Operations about S1’s personnel record and the information it contained about this incident, and reviewed relevant documents. The information revealed on 10/31/2020, it was reported thatR1’s call button was not responded to despite calling 9 times and R1 was found on the floor at 10:30 pm. S1 stated they checked on the resident between 9:20 pm and 9:30 pm. S1 stated they did not see any call light, that their beeper was always on, and they never let the lights go unattended. The internal investigation notes revealed R1 was found undressed and their nightgown was wet. S1 resigned on 11/7/2020. Based on the information obtained from the incident report, interviews and the facility’s internal investigation, the allegation is deemed Substantiated at this time.

On the allegation: Staff did not ensure Resident had access to meal(s). It was alleged that residents did not get adequate food or beverages during the COVID-19 pandemic when food was delivered to the rooms. LPA reviewed the staff schedule for May 2021. The schedule indicates one cook in the morning from approximately 5:30 am to 10:30 am most days. Then there is another cook 10 am to 7 pm. Tuesday 5/11/2021 indicates no morning cook, and only a cook from 10:30 am to 7 pm. The schedule shows 1 or 2 servers for breakfast, 1 to 2 servers for lunch, and 2-3 servers for dinner. One resident interviewed indicated they had experienced delays in being served before, and stated they waited over an hour for lunch on 5/16/2021. LPA interviewed Resident 1 (R1)’s Responsible Party (RP), who indicated they visited R1 at least once where R1 was in a chair, and food was left on a table far away that R1 was unable to access on their
Please continue to 9099-C, Pg 3.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20210511080512
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/25/2023
NARRATIVE
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own due to mobility issues. RP also noted the food was still covered and was cold. LPA interviewed another visitor for R1, who stated they observed R1 in their wheelchair parked and locked and could not get to the food. Former Administrator Stephanie Radu stated the staff forgot to provide tray service to the resident in room 147, as they were on hospice and needed to be fed by staff. Based on the information obtained, the allegation is deemed Substantiated at this time.
On the allegation: Staff does not respond to resident's call button in a timely manner. It was alleged that R1’s call button was not answered timely, and staff would respond in about an hour. As a result, R1 had to try to use the restroom alone, resulting in falls. Additionally, it was alleged that R1 used their call button to be assisted with feeding but no one responded. LPA reviewed the staff schedule for February through May 2021. The schedule indicates on average, there are 2 AM caregivers and 1 med tech, 2 PM caregivers and 1 med tech, and 1 NOC caregiver. Multiple AM and PM shifts were noted where there was only 1 caregiver on shift. In May of 2021, there were 66 residents at the facility. LPA reviewed a sample of call button logs from 4/18/2021 to 5/18/2021. LPA observed 108 calls that were responded to between 20-29 minutes, 35 calls that were responded to between 30-60 minutes, 101 calls that state they were never responded to. Residents interviewed also indicated sometimes it took staff a while to respond to the call buttons. Responsible Party for R1 stated R1 often told them they would use their call button, and no one would respond. Based on the information obtained, the allegation is deemed Substantiated at this time.
On the allegation: Staff did not accord privacy to Resident in care. It was alleged that R1 was not given privacy during visits, as staff overheard conversations and provided input. LPA interviewed R1’s Responsible Party (RP), who stated Former Administrator Stephanie Radu “eavesdropped” on visitor conversations and would interject if the resident was speaking negatively about the facility. R1 reported to visitors there were no activities and they had to eat alone, and Radu interrupted the conversation saying, “That’s not true.” LPA interviewed another visitor for R1, who confirmed the same incident. Based on the information obtained, the allegation is deemed Substantiated at this time. Former Administrator Stephanie Radu is no longer at the facility, and a personal rights citation was issued for a similar issue with Radu’s conduct on 10/5/2022.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC9099-D):



Exit interview conducted. Deficiencies cited on 9099-D. Report and appeal rights mailed and emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20210511080512
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) …Residents…have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Facility is closed.
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This requirement was not met as evidenced by:
Based on interviews, the licensee did not ensure resident’s call buttons were responded to timely or meal service needs were met, which posed an immediate 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/11/2021 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20210511080512

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:0CENSUS: 0DATE:
05/25/2023
UNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Rick Olds, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not offer activities to Resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kontilis issued final findings for this investigation via certified mail, regular mail and email. The facility closed on 3/24/2023.
During the initial investigation visit on 5/18/2021 between 11:03 am and 4:15 pm, LPA conducted staff interviews, resident interviews, and reviewed relevant documents. LPA conducted a subsequent visit on 9/29/2021 from 1:30 pm to 3:30 pm to conduct additional interviews and obtain additional documents. LPA interviewed resident’s responsible party on 3/29/2023 and witnesses on 4/4/2023. LPA interviewed residents and staff on 5/2/2023 at 1:22 pm, 5/3/2023 from 10:13 am to 2:50 pm, and 5/15/2023 at 9:30 am. LPA interviewed Director of Operations on 5/22/2023 at 3:11 pm.
On the allegation: Staff did not offer activities to Resident in care. It was alleged that during the COVID-19 pandemic, the facility did not provide activities for residents. It was reported that R1 felt alone and isolated as a result.

Please continue to 9099-C, Pg 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20210511080512
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/25/2023
NARRATIVE
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LPA interviewed Former Administrator Stephanie Radu about activities. Radu stated the facility has activities and they are offered but residents are not required to participate. Radu stated they have chair exercise, sing-alongs, happy hour every Wednesday, and the residents come and go as they wish. Radu stated they were aware R1 played bingo every day at their previous facility, but this facility was not offering bingo every day and recommended to R1’s visitors they could play bingo with R1 everyday if they want to. LPA interviewed a witness about activities. Witness stated in 2021 the facility was not offering group activities due to public health restrictions on COVID-19 at the time. Witness stated they were aware families were unhappy regarding the restrictions at the time. R1’s Responsible Party (RP) stated the facility played bingo, but only so that one person could win. RP stated it was different from ‘basic’ bingo, and R1 did not like it. RP stated R1 liked music and there was a music performance at the facility, and he asked staff to please take R1 to it. R1 told RP she did not get to go because the staff did not pick her up from her room and assist her. R1’s care plan indicates they need escorting to and from activities. Staff interviewed indicated they were unaware of not offering activities, except during COVID outbreaks when group activities were restricted. LPA interviewed a staff who indicated R1 never went to activities because they didn’t like to, although they did like music. LPA interviewed residents who stated the facility had activities and they had never heard of residents being excluded from activities. Based on the information obtained the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report issued via email and USPS.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6