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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802116
Report Date: 01/15/2026
Date Signed: 01/15/2026 02:27:30 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
05/01/2025 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20250501113652
FACILITY NAME:SANTA BARBARA MEMORY CAREFACILITY NUMBER:
425802116
ADMINISTRATOR:LISA GERRFACILITY TYPE:
740
ADDRESS:325 W ISLAY STTELEPHONE:
(805) 880-4770
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:36CENSUS: 16DATE:
01/15/2026
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator, Lisa GerrTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Due to lack of supervision, resident came in resident's room and "pooped" on resident's belongings.
Due to lack of supervision, resident physically assaulted resident.

INVESTIGATION FINDINGS:
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 On 01/15/2026, Licensing Program Analyst (LPA) Jeffries conducted a subsequent complaint visit to issue final findings on the allegations above. LPA met with Administrator, Lisa Gerr, explained the purpose of the visit. On 5/2/2025 from 11:40am to 3:00pm, LPA Kontilis conducted an initial complaint visit to obtain documents and interview staff and administrator. LPA conducted interviews with R1 on 5/28/2025 at 11:05am and 5/30/2025 at 11:13am. LPA Jeffries interviewed administrator on 01/15/2026 at 1:00pm.

On the allegation: Due to lack of supervision, resident came in resident's room and "pooped" on resident's belongings. It was alleged in March 2025, a resident came into Resident 1 (R1)’s room and “pooped” on R1’s belongings. R1 stated they were moving to a different room in the facility and smelled something. R1 stated they went closer to a box that had their items packed in it, and it smelled bad like feces. R1 stated the Administrator was in denial at first but many people knew what happened so they could not deny it anymore. R1 stated staff had gloves on and were taking the box out.
CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
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-20250501113652
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: SANTA BARBARA MEMORY CARE
FACILITY NUMBER: 425802116
VISIT DATE: 01/15/2026
NARRATIVE
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 R1 stated the Administrator was in denial at first but many people knew what happened so they could not deny it anymore. R1 stated staff had gloves on and were taking the box out. LPA reviewed text messages between the Administrator and RP discussing the incident. The messages show RP stating they think the resident who pooped in the box may be the same one that came into R1’s room at night. LPA reviewed message from Administrator, that discusses the resident R1 was concerned about “who had been coming into [R1’s] room.” The message states the resident’s doctor has been contacted and they do not expect any more issues, and in the meantime staff will keep a close eye on the resident. On 01/15/2026 LPA Jeffries conducted an interview with Administrator who stated,On 01/15/2026 LPA Jeffries conducted an interview with Administrator, Lisa Gerr, who stated R2 did have observed elevated behaviors and were addressed by physician days after two incidents pertaining to this complaint. LPA Jeffries noted on prior visit to the facility on 05/21/2026 that facility was short on staff and was addressed in a case management visit report on 05/21/2026. Based on the information obtained, the allegation is Substantiated at this time.
On the allegation: Due to lack of supervision, resident physically assaulted resident. It was alleged a resident came into R1’s room at night, ripped the blankets off R1 and grabbed R1’s arms. Staff interviewed stated there was an incident one night where Resident 2 (R2) wandered into R1’s room. Administrator stated R2 had experienced a change in demeanor, with wandering, going into other resident’s rooms, moving a shirt from room to room. Administrator stated they had informed R2’s physician and responsible parties, and watched R2 more closely with hourly checks. Administrator stated R2 had become more aggressive to R1. Administrator stated R1’s RP informed them a resident came into the room and “attacked” R1. Administrator stated they were no injuries, and they gave R1 a lock for their door. Administrator stated the same evening R2 gave unwanted advanced to a visitor, and the Administrator tried to redirect them, but R2 gave them an angry look. Administrator stated they had another appointment scheduled with R2’s physician on 5/6/2025 due to the increased behaviors. Administrator stated they offered R1 anything they needed to feel safe aside from the lock on the door. When interviewed, R1 stated a resident was ripping blankets out of their hand, and was grabbing them. R1 confirmed the Administrator got them a key for their door, but someone could come through the bathroom. R1 stated they were told R2 also went into another resident’s room and was standing over their bed staring at them. LPA reviewed text messages between the Administrator and RP discussing the incident. The messages show RP stating they think the resident who pooped in the box may be the same one that came into R1’s room at night. LPA reviewed message from Administrator, that discusses the resident R1 was concerned about “who had been coming into [R1’s] room.” The message states the resident’s doctor has been contacted and they do not expect any more issues, and in the meantime staff will keep a close eye on the resident. Based on the information obtained, the allegation is Substantiated at this time.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20250501113652
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: SANTA BARBARA MEMORY CARE
FACILITY NUMBER: 425802116
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2026
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:
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Adminsitrator, in the month of May 2025 incresed staffing in facility. Additional position was added in June 2025, to address resident supervisional needs. Administrator emalied staff io LPA.
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Based on interview and record review, the licensee did not comply with the section cited above when staff provided inadequate supervision to R2, which posed a potential health, safety, and personal rights 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 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
05/01/2025 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20250501113652

FACILITY NAME:SANTA BARBARA MEMORY CAREFACILITY NUMBER:
425802116
ADMINISTRATOR:LISA GERRFACILITY TYPE:
740
ADDRESS:325 W ISLAY STTELEPHONE:
(805) 880-4770
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:36CENSUS: 15DATE:
01/15/2026
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator, Lisa GerrTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not treat resident with respect
INVESTIGATION FINDINGS:
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 On the allegation: Staff do not treat resident with respect. It was alleged the Administrator, Lisa Gerr, yelled at R1 about a lack of payment. Per R1’s Responsible Party (RP), R1 went to the hospital shortly after the interaction and R1 stated they were in the hospital for heart problems caused by the Administrator treating them badly. LPA interviewed a staff, who stated R1 was not at the facility and they heard there was “some kind of blow up” between the Administrator and R1. Administrator stated there was an incident where R1 wanted their medications. Administrator stated R1 was “screaming a tantrum.” Administrator stated R1 could have their medications but they were not going to just hand over a bag of morphine. Administrator stated they were going to count the pills first and create a release form, since the pills could be dangerous. Administrator stated they believed R1’s demeanor was related to their medical treatment. LPA reviewed text messages between Administrator and RP that indicate R1 was welcome to get the medications, but the Administrator needed to be present in the facility to prepare the medication and sign the release.

CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20250501113652
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: SANTA BARBARA MEMORY CARE
FACILITY NUMBER: 425802116
VISIT DATE: 01/15/2026
NARRATIVE
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 The Administrator gave their next available time at the facility. During interviews, R1 indicated they believed the Administrator was “brainwashing” them to turn against their RP. R1 also stated they had panic attacks. R1 stated they had just had a medical treatment that takes a toll on them, and then Administrator explained aspects of the lease or admission agreement. When R1 put on glasses and read the documents, they were different and they felt the Administrator had “lied.” R1 stated the Administrator made them upset and they ended up in the hospital with atrial fibrillation. R1 was unable to be interviewed any further. RP stated although R1 did not have dementia, they felt R1’s medical treatments were affecting some parts of R1’s memory. Staff interviewed confirmed R1 had memory issues, and in the staff’s opinion, was confused, very anxious, could get “rattled.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. The Administrator is reminded to conduct themselves in an appropriate manner at all times that ensures residents are treated with respect.

Exit interview conducted. Copy of report issued at the time of the visit.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5