425802106-5-13-2026-29-AS-KBUY-DUHRDZ-20260528125647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802106
Report Date: 05/13/2026
Date Signed: 05/13/2026 04:09:08 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2026 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20260213094231

FACILITY NAME:	WESTMONT OF SANTA BARBARA		FACILITY NUMBER:	425802106
ADMINISTRATOR:	JADE ALMA-HARRIS		FACILITY TYPE:	740
ADDRESS:	190 VIAJERO DR		TELEPHONE:	(805) 265-4327
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	99	CENSUS: 66	DATE:	05/13/2026
		UNANNOUNCED	TIME BEGAN:	03:23 PM
MET WITH:	Jade Alma-Harris, Administrator		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff are not trained properly in transferring and repositioning resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility to deliver final findings of the allegations. LPA met with Jade Alma-Harris Administrator and explained the purpose of the visit.

LPA De Leon conducted the initial 10-day visit on 02/13/2026 and collected records pertaining to the investigation. LPA interviewed staff on 05/12/2026 at 11:47am and 12:01pm. LPA interviewed witnesses on 05/04/26 at 12:56pm and on 05/12/2026 at 4:06pm. LPA received emails from Administrator regarding complaints on 02/20/2026, 05/05/2026, and 05/12/2026. LPA received emails from Complainant on 02/12/2026 and 02/13/2026.

On the allegation: Staff are not trained properly in transferring and repositioning resident. It was alleged staff were not properly repositioning residents, had to ask other staff what to do, and were roughly handling residents due to improper technique. Continued 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 29-AS-20260213094231

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/13/2026

NARRATIVE

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LPA De Leon reviewed the facility training records provided by the Administrator specific to Resident transfers, positioning of bed bound patients, 1 or 2 person assists, and hospice care.

On 01/07/2026, 28 Wellness staff participated in an All Staff On-site service training on the topics of Body Mechanics, Positioning, Moving, and Transfers, How to Properly Position Bed Bound Patients, and Get a Lift Buddy. Staff 1 (S1) and Staff 2 (S2) took this training and were listed on the sign in sheets.

Twelve Wellness staff took a Competency Verification on Transferring in 2025, Staff 2 was present with a mentor and completed Procedure/Steps/Bed to Chair/Wheelchair/Bed to Walker and Wheelchair to Chair, S2 had a satisfactory completion by a Mentor, S1 did not appear to have a Competency Verification on Transferring based on the records the facility provided LPA.

Course Enrollments in online courses were taken by staff with completion dates in 2024-2026 on the Topic of Transferring Safety, 15 staff had completed this course, S2 had completed this course on 06/09/2025, S1 had not completed this course based on records provided.

Another course was taken online called Restorative Nursing: Positioning & ROM for Nursing Assistants 14 staff completed this course with completion dates in 2024-2026, S1 completed this training course on 01/05/2026 and S2 completed this course on 06/11/2025.

LPA requested Hospice Training records for Resident 1(R1) Administrator could not provide any records of staff training provided by hospice personnel for R1’s hospice care plan, which included transferring and repositioning. R1 was on Hospice services and experienced baseline pain, and sometimes staff used a sheet to help transfer R1 to reduce pain from transfers. R1 was a 2-person assist. A witness stated the staff lacked training to do the repositioning and were not using a sheet so staff would cause R1 pain. Overall, the investigation revealed two staff provided care to Hospice Resident (R1) without Hospice training and records specific to individual R1’s Hospice Care Plan.

Based on the evidence this allegation is Substantiated at this time.

Exit interview conducted and copy of report emailed tor Administrator per request.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20260213094231

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/13/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/20/2026 Section Cited CCR 87633(b)(6)(B)	1 2 3 4 5 6 7	(b)A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:(6)Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee’s responsibilities for implementation of the hospice care plan. (B)The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to read and review 87633, provide a statement of understanding, have hospice agency nurse train a facility lead staff on proper repositioning and transferring for residents on hospice services, then the lead staff can train all wellness staff -Cont. below-
	8 9 10 11 12 13 14	Based on record review the Licensee did not comply with the regulation above in 2 staff provided care to Hospice Resident (R1) without Hospice training and records specific to the individual R1’s Hospice Care Plan which poses an potential safety and personal rights risk to residents in care.	8 9 10 11 12 13 14	working with Hospice residents, provide proof of trainings and materials used with staff signatures and an up to date LIC 500 to CCL.
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2026 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20260213094231

FACILITY NAME:	WESTMONT OF SANTA BARBARA		FACILITY NUMBER:	425802106
ADMINISTRATOR:	JADE ALMA-HARRIS		FACILITY TYPE:	740
ADDRESS:	190 VIAJERO DR		TELEPHONE:	(805) 265-4327
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	99	CENSUS: 66	DATE:	05/13/2026
		UNANNOUNCED	TIME BEGAN:	03:23 PM
MET WITH:	Jade Alma-Harris, Administrator		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff handled resident roughly causing pain

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility to deliver final findings of the allegations. LPA met with Jade Alma Harris Administrator and explained the purpose of the visit.

LPA De Leon conducted the initial 10-day visit on 02/13/2026 and collected records pertaining to the investigation. LPA interviewed staff on 05/12/2026 at 11:47am and 12:01pm. LPA interviewed witnesses on 05/04/26 at 12:56pm and on 05/12/2026 at 4:06pm. LPA received emails from Administrator regarding complaints on 02/20/2026, 05/05/2026, and 05/12/2026. LPA received emails from Complainant on 02/12/2026 and 02/13/2026.

On the allegation: Staff handled resident roughly causing pain. LPA interviewed Wellness Staff which revealed R1 was in pain prior to Hospice services and even more pain as R1 was transferred and repositioned on Hospice services. Continued 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20260213094231

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/13/2026

NARRATIVE

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Staff would try to do the best job staff could but R1 was clearly in pain and when staff would have to touch R1 to reposition R1 would moan and groan in pain, sometimes the sheet would come down under R1 and one staff would have to touch R1 to hold R1 as the other staff would pull the sheet back up under R1 so that the staff could reposition R1 with a sheet under R1 and not have to physically touch R1 to reduce the pain R1 was in already. R1 was a 2-person assist. A witness stated the staff lacked training to do the repositioning and were not using a sheet so staff would cause R1 pain. Another Witness interview revealed the staff did not handle R1 roughly, R1 was in pain, R1’s family did not want R1 on certain pain medications to help R1’s pain, the facility staff are caring and did not feel staff were under trained or understaffed but felt staff could always use more training. Witness stated the best thing for R1’s care and pain would have been a Hoyer Lift for repositioning and transferring but unfortunately the facility policy does not allow Hoyer Lifts in the facility, and that could have avoided added pain when transferring and repositioning, R1 declined rapidly and in was in pain which had nothing to do with the staffing and more so to do with R1’s transitioning. Based on the lack of evidence this allegation is Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

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