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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802116
Report Date: 02/24/2025
Date Signed: 02/26/2025 07:52:16 AM

Document Has Been Signed on 02/26/2025 07:52 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:SANTA BARBARA MEMORY CAREFACILITY NUMBER:
425802116
ADMINISTRATOR/
DIRECTOR:		LISA GERRFACILITY TYPE:
740
ADDRESS:325 W ISLAY STTELEPHONE:
(805) 880-4770
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY: 36CENSUS: 14DATE:
02/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Lisa Gerr, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required Inspection of the facility. At the time of arrival, there were fourteen (14) residents in care and two staff, Business Office Manager, and Administrator Lisa Gerr on duty. LPA met with Lisa Gerr, Administrator and explained the purpose of the visit.

Entrance interview conducted:
The facility is a one-story Residential Care Facility for the Elderly (RCFE) with a capacity of thirty-six (36) residents. The facility is a memory care facility for residents with a dementia diagnosis. The facility has a fire clearance for thirty-six (36) non-ambulatory residents of which thirty-six (36) can be bedridden and has a hospice waiver for ten (10) residents. Currently, there are two (2) residents on hospice and no bedridden residents residing in the facility.
LPA and BOD toured the facility to assess the physical environment and accommodations. The following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights.
Upon entry, there is a gate that requires a code to enter the premises and a phone number posted to the facility for those who do not have a code. Entering through the gate, is a large walkway and driveway leading up to a large front patio with seating areas including patio chairs, tables with umbrellas, couches, and mini-couches.
Entering past the patio area, the administrator’s office is located on the west side of the building. Staff files and other confidential information is kept in the administrator’s office.
Entering into the main area of the facility is the dining area/common area on the east side of the room. Socializing, meals, and activities are held in the dining/common area.

Please continue to 809-C, Pg 2.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
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: SANTA BARBARA MEMORY CARE
FACILITY NUMBER: 425802116
VISIT DATE: 02/24/2025
NARRATIVE
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 The kitchen is located at the back of the dining/common area and is inaccessible to residents in care. LPA observed seven (7) days of non-perishable food items and two (2) days of perishable food items.
LPA observed approximately 16 heads of iceberg lettuce loosely in a box without proper packaging and date stamped.
LPA reviewed Resident 1's (R1's) hospice file and determined no hospice notification has been submitted to CCLD within five (5) business of having been placed on hospice.
At approximately 3:19 pm, LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster. Record review revealed Staff 1 (S1) has worked in the facility since 8/23/2024 and has not been properly associated to the facility prior to employment; Staff 2 (S2) has worked in the facility since 11/1/2024 and has not been properly associated to the facility; and, Staff 3 (S3) who was hired on or about 10/16/2024 has not been properly associated to the facility.

Due to time restraints, LPA will return at a later date to continue the annual inspection.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. Due to technical difficulties, copy of report and Appeal Rights issued via email.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/26/2025 07:52 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 02/24/2025 at 04:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SANTA BARBARA MEMORY CARE
FACILITY NUMBER: 425802116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355(e)(2) Criminal Background Clearance: 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)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Record review and interview conducted revealed the licensee did not comply with the section cited above when three (3) staff members were not properly associated to the facility prior to working, residing, and/or volunteering in the facility which poses an immediate health and safety risk to residents in care.
POC Due Date: 02/25/2025
Plan of Correction
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Administrator properly associated S1, S2, and S3 to the facility at the time of the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/26/2025 07:52 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 02/24/2025 at 04:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SANTA BARBARA MEMORY CARE
FACILITY NUMBER: 425802116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(d)(2)
87632(d)(2) Hospice Care Waiver: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Record review revealed the licensee did not comply with the section cited above when CCLD was not notified of Resident 1’s (R1’s) placement of hospice on or about 6/11/2024 which poses a potential health and safety risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Adminstrator agrees to submit hospice notifications within five (5) business days of when a resident has been placed on hospice.
Administrator agrees to submit a hospice notification for R1 no later than the POC due date.
Type B
Section Cited
CCR
87355(b)(9)
87555(b)(9) General Food Service Requirements: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that approximately 16 heads of iceberg lettuce were observed in the refrigerator and food storage area are not stored properly which poses a potential health and safety risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Administrator agrees to conduct in-service with kitchen staff and Food Service Director to ensure proper protocols are followed in storing and packaging.
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 Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
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