425800837-6-14-2021-29-AS-KKOS-C3YVZN-20210614165258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800837
Report Date: 06/11/2021
Date Signed: 06/14/2021 04:53:28 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 BARBARA		FACILITY NUMBER:	425800837
ADMINISTRATOR:	STEFANIA RADU		FACILITY TYPE:	740
ADDRESS:	227 E. ANAPAMU STREET		TELEPHONE:	(805) 963-4428
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY:	126	CENSUS: 64	DATE:	06/11/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	William Ferguson, Director of Operations		TIME COMPLETED:	05:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Toan Luong and Kristin Kontilis conducted an onsite one-year infection control annual visit to the above-named facility. LPAs met with William “Bill” Ferguson, Director of Operations and Anthony Gonzales, Wellness Director and explained the purpose of today's visit. LPAs conducted a physical tour of the facility. The facility has submitted a Mitigation Plan to the Department and is currently under review. LPAs reviewed the Infection Inspection Control Module with Anthony Gonzales. The facility has a reception desk upon entrance into the building. Upon entry, staff and visitors are required to sign-in, complete a symptom questionnaire, and have a temperature screening. A temperature check is conducted when residents have returned to the facility from an outing. Residents’ documentation is kept in a binder on a daily basis. Staff and visitor documentation is kept in the reception office. A hand sanitizer dispenser is located at the reception area. PPE gear is available to visitors, staff, and residents at the reception desk. LPAs toured the facility and the following was noted: The facility is not approved for memory care and does not have a dementia care plan. The facility has signs posted as required by Title 22 Regulations. LPAs toured the common areas which were found to be maintained in a safe manner. The library, television area, activity room, theater room, and outdoor patio were inspected and found to be maintained in a safe manner. The outdoor seating areas provide adequate shade for the residents in care. LPAs inspected all common area bathrooms which were maintained with grab bars at the toilets. The dining area is maintained in a clean safe manner. The kitchen was inspected and found to have sufficient perishable and non-perishable food supply on hand. There is sufficient food for emergency food supply. There is a separate storage closet used for chemical cleaners. LPAs observed three fire extinguishers on the third floor inspected on 11/1/2021; five fire extinguishers on the second floor inspected on 11/3/2021; and, three fire extinguishers on the ground floor inspected on 11/3/2021. Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

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
	VISIT DATE: 06/11/2021

NARRATIVE

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At approximately 11:39 am, LPAs observed an unlocked and unattended Medication Cart (Med Cart 1) in the hallway of the first floor next to the entrance of a resident’s room. LPAs observed bubble pack prescriptions, ointments, medication cups, over-the-counter medications, narcotic binder, and approximately 9 bottles of sucralfate. Medication cart was unlocked and accessible to residents in care. LPAs observed narcotic box was locked inside the unlocked medication cart. At 11:42 am, LPA Luong locked the medication cart.
At approximately 12:50 pm, LPAs conducted a medication audit of Med Cart 1. Audited medications were found to have been given as prescribed.

Exit interview conducted, copy of report given, citation issued, (See 809-D).

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

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: 06/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation and interview, medication cart (Med Cart 1) located on first floor of the facility was left unattended and unlocked which poses an immediate health and safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, medication cart (Med Cart 1) located on the first floor of the facility was left unattended and unlocked which poses an immediate health, safety to persons in care.
	POC Due Date: 06/14/2021
	Plan of Correction
1 2 3 4	Wellness Coordinator agrees to conduct medication training to all Med Techs. Documentation as to when training will be conducted will be submitted to CCL no later than 6/14/2021. Training to include regulation review of CCR 87465 in its entirety. Documentation to include attendees, date of training, duration, individuals conducting the training, and a copy of the training materials.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

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