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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802106
Report Date: 07/02/2024
Date Signed: 07/02/2024 04:03:19 PM


Document Has Been Signed on 07/02/2024 04:03 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:WESTMONT OF SANTA BARBARAFACILITY NUMBER:
425802106
ADMINISTRATOR:MARK CORTESFACILITY TYPE:
740
ADDRESS:190 VIAJERO DRTELEPHONE:
(805) 265-4327
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:99CENSUS: 71DATE:
07/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Jessica Zebroski, Resident Services Director Specialist, Westmont Living, San Diego, CATIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management visit to issue additional deficiencies discovered while investigating complaints at this facility and reviewing incident reports. LPA met with Ernest "EJ" Lewis, Acting Executive Director and Jessica Zebroski, Resident Services Director Specialist, Westmont Living, San Diego, CA. LPA explained the purpose of the visit. During the investigation, LPA Kontilis reviewed relevant documents and interviewed staff.
On 5/29/2024, LPA Kontilis received a call from interim Administrator Sheryl McCaskill, who reported medication errors. McCaskill reported a new staff (Staff 1 – S1) did not provide morning medications to 21 residents on 5/27/2024, due to “being overwhelmed.” McCaskill stated S1 did not reach out to the facility management for assistance or for notification. On 6/1/2024, CCL received 10 incident reports for the medication errors. The following medication errors were noted on 5/27/2024:
-R1 did not receive their 8:00 am dose of Citalopram 10 mg, or Preparation H cream.
-R2 did not receive their 8:00 am dose of Escitalopram 5mg.|
-R3 did not receive their 8:00 am dose of Acetaminophen 325mg, Metoprolol 25mg, or Risperidone 0.5mg.
-R4 did not receive their 8:00 am dose of Famotidine 20mg, Nitrofurantoin Mono MCR 100 mg, Pravastatin 40mg, Quetiapine Fumarate 25mg, or Valsartan 80mg.
-R5 did not receive their 8:00 am dose of Astrovastin 20mg, Furosemide 20mg, Jardiance 10mg, Metoprolol 25mg, Mirtazapine 7.5mg, Spironol Actone 25mg, or Xarelto 15mg.
-R6 did not receive their 8:00 am dose of Naproxen 500mg.
-R7 did not receive their 8:00 am dose of Pantoprazole 20mg, Aripiprazole 5mg, Aspirin 81mg, Calcium Citrate 200mg, Carvedilol 3.125mg, Ferrous Sulfate 325mg, Finasteride 5mg, Januvia 25mg, Jardiance 10mg, Multivitamin/Minteral, Pioglitazone HCL 30mg, Sertraline HCL 50mg, or Vitamin D3 1000 unit.
-R8 did not receive their 8:00 am dose of Senna 8.6mg, or Tramadol 50mg.
-R9 did not receive their 8:00 am dose of Donepezil HCL 10mg, Glimepride 4mg, Lisinopril 2mg, Metformin HCL 500mg, or Simvastatin 20mg.
-R10 did not receive their 8:00 am dose of Donepezil 10mg, or Eliquis 2.5mg.
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: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
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: WESTMONT OF SANTA BARBARA
FACILITY NUMBER: 425802106
VISIT DATE: 07/02/2024
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The incident reports indicate all resident’s physicians and responsible parties were contacted regarding the medication errors. Additionally, all affected residents were placed on alert charting for a minimum of three days for adverse reactions. S1 received a corrective counselling memo and was retrained on the medication process.
Interview with Interim Administrator revealed no severe adverse reactions occurred that required further medical treatment. A deficiency will be issued for failure to provide medication as prescribed.
On 7/2/2024, LPA Kontilis confirmed 21 residents were not prescribed morning medications on 5/27/2024 and only 10 of the 21 were reported to CCLD.
Additionally, During the investigation, LPA was also informed that the facility’s bus was involved in an accident on the afternoon of 3/8/2024. On 6/13/2024, LPA briefly discussed the accident with acting Administrator McCaskill. McCaskill asked if they should submit an incident report still, even though it was late, and LPA informed McCaskill they should submit the incident report to the Department. McCaskill acknowledged the incident should have been reported, as three residents were on the van at the time. As of 7/2/204, no incident report has been received.
The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. Due to technical difficulties, a copy of the report and appeal rights issued via email.

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

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/02/2024 04:03 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: WESTMONT OF SANTA BARBARA
FACILITY NUMBER: 425802106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2024
Section Cited
CCR
87465

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87465 Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidenced by:
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Acting Executive Director agrees to provide proof S1 was retrained in mediation procedures. Acting Executive Director agrees to submit a written plan to ensure residents will receive their medication as prescribed.
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Based on interview and record review, the licensee did not comply with the section cited when multiple residents did not receive their medication as prescribed, which posed an immediate health and safety risk to residents in care.
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Type B
07/08/2024
Section Cited
CCR87211

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87211 Reporting Requirements. A written report shall be submitted to the licensing agency…Any incident which threatens the welfare, safety, or health of any resident…

This requirement was not met as evidenced by:
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Acting Executive Director agrees to provide a written incident reports, as well as a written statement of understanding of 87211 Reporting Requirements.
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Based on interview and record review, the licensee did not comply with the section cited above when they failed to report a bus accident involving residents and medication errors, 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
LIC809 (FAS) - (06/04)
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