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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802116
Report Date: 03/19/2025
Date Signed: 03/20/2025 08:49:10 AM

Document Has Been Signed on 03/20/2025 08:49 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: 36TOTAL ENROLLED CHILDREN: 0CENSUS: 16DATE:
03/19/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Lisa Gerr, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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This Case Management visit was conducted to address deficiencies noted during Complaint Control #29-AS-20250310083615 investigation visit conducted on 3/19/2025. The Case Management visit is being conducted to discuss the reporting of a death requirement as per regulation 87211(a)(1)(A) Reporting Requirements.

During today’s visit, documents reviewed revealed on 3/11/2025 CCLD received LIC624A stating on 3/3/2025 Resident 1 (R1) passed away due to “metabolic encephalopathy and adult failure to thrive”. Administrator Gerr stated R1 was not on hospice and not reporting it within the seven day requirement was “an oversight”.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. Copy of report issued at the time of the visit.

Kelly BurleyTELEPHONE: (805) 562-0413
Kristin KontilisTELEPHONE: (805) 689-2787
DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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Document Has Been Signed on 03/20/2025 08:49 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: SANTA BARBARA MEMORY CARE
FACILITY NUMBER: 425802116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2025
Section Cited
CCR
87211(a)(1)A

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87211(a(1)(A) Reporting Requirements: Each licensee shall furnish …(A) Death of any resident from any cause regardless of where the death occurred...

This requirement is not met as evidenced by:
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Administrator agrees to provide written statement acknowledging the requirement of providing LIC624A Death Report within the required time.
Administrator agrees to submit written statement directly to LPA via email no later than POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above when death of a resident on 3/3/2025 was not reported to CCLD until 3/11/2025 which poses an immediate 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.
Kelly BurleyTELEPHONE: (805) 562-0413
Kristin KontilisTELEPHONE: (805) 689-2787

DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025

LIC809 (FAS) - (06/04)
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