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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802106
Report Date: 07/25/2024
Date Signed: 07/29/2024 11:56:59 AM


Document Has Been Signed on 07/29/2024 11:56 AM - 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: 68DATE:
07/25/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Ernest "EJ" Lewis, Acting Executive DirectorTIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management - Annual Continuation visit to the facility above. LPA met with Ernest “EJ” Lewis, Acting Executive Director and explained the purpose of the visit.

Entrance interview conducted:
LPA completed medication inventory and continued to review residents’ records for health screenings, Serious Illness/Injury reports, death reports, medication administration, appraisals, re-appraisals, admission agreements, and Physician’s reports.
Centrally Stored Medication Record: Record review and interviews revealed two prescribed medications were not listed on R1's Centrally Stored Medication Record.
Record review and interviews revealed the facility self-reported the following medication errors:
On 9/15/2023, Staff 1 (S1) discovered on 9/12/2023 PRN Acetaminophen bubble back was mixed into Resident 8’s (R8’s) routine medications. R8 was prescribed two tablets 3x/daily of Acetaminophen 500mg. S1 discovered R8 was administered 650mg of Acetaminophen instead of 1,000mg.
On 1/11/2024, CCL received an incident report stating on 1/4/2024 S1 removed R8’s Fentanyl 12mcg Patch that was applied on 1/2/2024 at 8:00 pm. Doctor's order states the patch is a 72-hour patch and should have been removed on 1/5/2024 at 8:00 pm. Per the incident report, S1 was "counselled with a Corrective Counseling Documentation, and was retrained on the process of administering fentanyl patch and was counseled to review of the physician order".
On 5/16/2024, CCL received an incident report stating on 5/7/2024, Resident 9 (R9) was transported via ambulance to the hospital due to being unresponsive. LIC624 states R9 received a diagnosis of “morphine overdose”.

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: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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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Document Has Been Signed on 07/29/2024 11:56 AM - 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: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observation, the licensee did not comply with the section cited above as staff trainings do not include a minimum of four hours per year of training in postural support, restricted health conditions, and hospice care which poses an immediate health, safety or personal rights risk to persons in care..
POC Due Date: 07/30/2024
Plan of Correction
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Acting Executive Director agrees to conduct all-staff trainings no later than due date (7/30/2024). Acting Executive Director agrees to submit proof of training via email to LPA no later than 7/30/2024. Proof of training to LPA via email to include first and last name and signature of trainee, descriptions of training, dates completed, and duration of training.
Type A
Section Cited
CCR
87506(b)(17)(A)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above when a Pre-Appraisal was not conducted for Resident 10 (R10) prior to admission into the facility on or before 3/27/2023 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2024
Plan of Correction
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Acting Executive Director agrees to provide an updated appraisal for R10 no later than POC due date of 7/27/2024.
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: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2024 11:57 AM - 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: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465
87465(c)(2) Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited when residents did not receive their medication as prescribed, which posed an immediate health and safety risk to residents in care.
POC Due Date: 07/27/2024
Plan of Correction
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Acting Executive Director stated S1 is no longer employed with the facility. Acting Executive Director agrees to submit a written plan to ensure residents will receive their medication as prescribed.
Type A
Section Cited
CCR
87465(h)(4)
87465(h)(4) Incidental Medical and Dental Care: All centrally stored medications shall be labeled and maintained in compliance with state and federal laws…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited when Resident 1’s IR1’s) Centrally Stored Medication Record did not list two prescribed medications.
POC Due Date: 07/27/2024
Plan of Correction
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Acting Executive Director agrees to provide proof that R1’s Centrally Stored Medication Record reflects all prescribed medications.
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: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


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: 07/25/2024
NARRATIVE
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During today's visit, a tour of the facility revealed the east patio area between the Assisted Living and Memory Care patios were unclean and unsanitary. Acting Executive Director stated the Licensee has approved an estimate/quote for a "spray wash" to be conducted on the patio areas. Acting Executive Director stated the facility currently does not have a maintenance director and a maintenance technician is available two days a week to assist with maintenance needs.
Record review and interviews conducted revealed on or about 5/10/2024 the previous administrator resigned as administrator from the facility. In the interim, Sheryl McCaskill, Operations Specialist was present in the facility. On or about 6/24/2024 Acting Executive Director Ernest "EJ" Lewis began his tenure at the facility. As of today's visit, Licensee has not submitted required paperwork to CCLD naming Acting Executive Director as the current administrator.

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. Copy of report issued at the time of the visit.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/29/2024 11:57 AM - 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: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview conducted, the licensee did not comply with the section cited above when the outside patio areas between Assisted Living and Memory Care were observed to be unclean and not sanitary due to birds nesting in the area.
POC Due Date: 07/30/2024
Plan of Correction
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Acting Executive Director agrees to provide proof via email that the patio areas have been cleaned.
Type B
Section Cited
CCR
87211(g)(1-3)
87211(g)(1-3) Reporting Requirements: The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: (1) Name and residence and mailing addresses of the new administrator. (2) Date he/she assumed his/her position. (3) Description of his/her background and qualifications, including documentation of required education and administrator certification.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as previous Administrator was no longer employed on or about May 10, 2024; Licensee has not provided information to CCLD to name the previous Interim Administrator and/or current Acting Executive Director as Facility Administrator which poses a potential health and safety risk to residents in care.
POC Due Date: 07/30/2024
Plan of Correction
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Licensee shall submit required paperwork to CCLD via email naming Administrator to the facility. Required paperwork to be submitted no later than the POC due date (7/27/2024).
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: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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