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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 05:39:30 PM


Document Has Been Signed on 06/01/2022 05:39 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 - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rick Olds, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LP) Kristin Kontilis conducted an unannounced Case Management - Deficiencies inspection at the facility today.

During the inspection, LPA conducted a health and safety tour of the facility. At 3:16 pm, LPA observed Staff 1 (S1) sitting at the medication desk who was not wearing a mask. At 3:17 pm, LPA observed Staff 2 (S2) exit the Wellness Center who was not wearing a mask. LPA advised both staff members staff are required to wear masks at all times while working in the facility.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations and/or Health and Safety Code, the following deficiency was cited (refer to LIC 809-D).

Exit interview was conducted, today's reports and appeal 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
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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Document Has Been Signed on 06/01/2022 05:39 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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87468.1 PERSONAL RIGHTS: Residents have the right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidenced by:
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Based on observations, the facility failed to ensure staff were wearing face coverings which poses an immediate health, safety and personal rights 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)
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