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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800837
Report Date: 06/01/2022
Date Signed: 06/01/2022 05:32:36 PM


Document Has Been Signed on 06/01/2022 05:32 PM - It Cannot Be Edited

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:RICK OLDSFACILITY TYPE:
740
ADDRESS:227 E. ANAPAMU STREETTELEPHONE:
(805) 963-4428
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:126CENSUS: 65DATE:
06/01/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rick Olds, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced continuance of an Annual Inspection and Infection Control Inspection visit to the facility. LPA continued the annual visit due from the inspection conducted on 5/31/2022. Upon arrival LPA met with Administrator Rick Olds and explained the reason for the visit.

Entrance Interview Conducted:
During the Annual Infection Control Inspection on 5/31/2022, observations were noted as follows:
At 1:15 pm, LPA and Administrator observed the door to the medication room was open and unlocked with no staff present at the time of the observation. Upon LPA’s request, Administrator closed the door and confirmed it was locked. At approximately 2:22 pm, Wellness Director stated current residents’ charts are kept in the medication room. Wellness Director further stated Staff 1 (S1), Staff 2 (S2), and Staff 3 (S3) were on today’s schedule and often are at the desk doing charting, training, and filing. LPA advised Administrator and Wellness Director of the Type A violation due to an immediate risk to residents in care and advised Administrator and Wellness Director to keep door into the medication room locked at all times when staff are not present at the nurses’ station and/or in the medication room.
At 1:18 pm, LPA and Administrator observed the door to the Wellness Director’s office located inside the Wellness Center was unlocked and open with no staff present at the time of the observation. Wellness Center Director stated the pharmaceutical destruction container with pharmaceuticals to be destroyed is kept in the Wellness Center Director’s office. At the time of the observation, Wellness Center Director was in Administrator’s office located on the ground floor of the facility. Upon LPA’s request, Administrator closed the door and confirmed it was locked at the time of the observation. LPA advised Administrator and Wellness Director of the Type A violation due to an immediate health and safety risk to residents in care and advised Administrator and Wellness Director to keep door into the Wellness Director’s office to be locked at all times when staff are not present in the Wellness Center..
Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
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: 06/01/2022
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 Staff records were reviewed from 2:20 pm through 3:30 pm. LPA noted Staff 4 (S4) has been working in the facility since 4/15/2022 and has not been associated to the facility; and Staff 5 (S5) has been working in the facility since 5/12/2022 and has not been associated to the facility. LPA advised Administrator and Business Office Manager that S4 and S5 cannot work in the facility until associations to the facility have been successfully completed. LPA confirmed that S4 and S5 were not on the staff schedule on this day and were not working in the facility at the time of the visit. Administrator confirmed that S4 and S5 will not work in the facility until a facility transfer association has been successfully completed.
Upon record review and observation, LPA determined personnel documents were incorrectly and inaccurately completed—the facility name was not accurately written on the association form and the facility’s CCL number was not included on the personnel documents.
Due to time restraints, at approximately 3:55 pm, LPA stated she would return as soon as possible to issue citations and penalties for the above noted deficiencies. LPM Desaree Perera approved LPA to return the following day to issue citations and penalties.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, today's reports, civil penalties and appeals rights were emailed to the Administrator.

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

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/01/2022 05:32 PM - It Cannot Be Edited

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: 06/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2022
Section Cited

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87506(c)(1) Residents Records: (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents…
This requirement is not met as evidenced by:
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Based on LPA's observation, the licensee did not comply with the section cited above as the door to the Nurse’s office in the medication room was left open and unattended which poses an immediate health and safety risk to residents in care.
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Type A
06/02/2022
Section Cited

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87465(h)(2) Incidental Medical and Dental Care: 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:
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Based on LPA's observation, the licensee did not comply with the section cited above as the door to the Wellness Director’s office where pharmaceuticals are stored was left open and unattended which poses 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: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/01/2022 05:32 PM - It Cannot Be Edited

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: 06/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2022
Section Cited

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87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or...
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This requirement is not met as evidenced by:
The licensee did not comply with the section cited above as S4 and S5 have been working in the facility and are not associated with the facility, which poses an immediate health and safety risk to residents in care.

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Civil Penalties issued

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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: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4