425802116-4-9-2026-29-AS-KBUY-DTL294-20260428171118

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802116
Report Date: 04/07/2026
Date Signed: 04/09/2026 02:37:44 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
03/10/2025 and conducted by Evaluator Kristin Kontilis

COMPLAINT CONTROL NUMBER: 29-AS-20250310083615

FACILITY NAME:	SANTA BARBARA MEMORY CARE		FACILITY NUMBER:	425802116
ADMINISTRATOR:	LISA GERR		FACILITY TYPE:	740
ADDRESS:	325 W ISLAY ST		TELEPHONE:	(805) 880-4770
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY:	36	CENSUS: 19	DATE:	04/07/2026
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Lisa Gerr, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Licensee did not protect resident from being inappropriately touched by another resident.
Staff does not provide a safe environment for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced subsequent complaint visit to deliver final findings for the above-stated allegations. During today’s visit, LPA met with Administrator Lisa Gerr and explained the purpose of the visit. LPA Kontilis conducted the initial visit on 3/19/2025 from approximately 12:15 pm to 3:45 pm at which time LPA conducted interviews and obtained documents pertaining to the investigation. On 4/16/2025 from approximately 11:00 am to 2:00 pm, LPA conducted a subsequent visit and a Case Management visit to the facility at which time LPA obtained documents and conducted interviews.
On the allegation, Staff did not protect resident from being inappropriately touched by another resident: Reporting Party voiced concern for residents’ safety when a resident was found in another resident’s room touching the other resident’s briefs and when the resident was re-directed out of that resident’s room, the resident stated they were directed to do so by another individual; however the resident was unable to identify the other individual. Records reviewed and interviews conducted revealed R1 has a diagnosis of neuropathy
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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250310083615

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: 04/07/2026

NARRATIVE

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and no diagnosis of dementia or mild cognitive impairment. All other residents in the facility have dementia or mild cognitive impairment. Interviews conducted revealed staff observed Resident 1 (R1) demonstrate inappropriate behavior towards other residents. Staff stated R1 was observed trying to go into other residents’ rooms and described R1’s behavior as “predatory”. Interviews conducted revealed R1 was observed with their hand between Resident 2’s (R2’s) legs and R1 “backed off” when R2 became combative towards R1. Interviews conducted revealed R1 was found “multiple times” with their hand on Resident 3’s (R3’s) breasts. Interviews conducted revealed Resident 4 (R4) demonstrated a different demeanor in R1’s presence and appeared to be “uncomfortable” when R1 was near R4. Interviews conducted revealed staff reported R1’s behavior and specific incidents to Administrator Gerr. Administrator responded saying the interactions are most likely consensual, especially between R1 and R4, and noted residents have personal rights. Staff stated they felt R1 followed and pursued R4, and coerced R4. The investigation revealed Administrator did not provide support or guidance to the staff and instead deflected the incidents by saying R1 had “their needs”. Staff indicated they were never directed to provide additional supervision to R1 or R4, despite the Administrator being aware of R1’s behaviors. Additionally, text messages and interviews revealed staff found R4 in R5’s room, with R4’s pants pulled down and the covers off of R5. Interviews revealed R4 was touching R5’s briefs. R5 was saying they did not need assistance, believing R4 to be a staff. R4 was very confused when staff intervened. Based on interviews conducted and records reviewed, the allegation Staff did not protect resident from being inappropriately touched by another resident is deemed Substantiated at this time.

On the allegation, Staff does not provide a safe environment for resident: Reporting Party voiced concern for a resident’s safety when staff reported to Administrator that R1 was demonstrating inappropriate behavior towards other residents. Interviews conducted revealed R1 was observed trying to enter other residents’ rooms and when R1 was “called out” on their behavior, R1 would “slink off” and go to their room. Interviews conducted revealed when R1 “was affectionate” towards residents in the dining room, and when R1 was told “No” by staff, R1 would then leave the area and go to their room.
Records review and interviews conducted revealed R1 has a diagnosis of neuropathy and no diagnosis of dementia or mild cognitive impairment. All other residents in the facility have dementia or mild cognitive impairment. By R1 residing in the facility, R1 is in an environment that is not compatible with their mental cognition and diagnosis. On 4/16/2025, LPA Kontilis conducted a Case Management visit to the facility wherein a citation was issued against the facility as a violation for admitting a resident who did not have a dementia diagnosis and did not require the level of care provided by the facility. The facility is a secured

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SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250310083615

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: 04/07/2026

NARRATIVE

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perimeter memory care facility, per regulation, all residents must have conservatorship to be in a secured perimeter memory care facility or a signed acknowledgment that they agree to be in a secured perimeter facility.
Based on the information obtained over the course of the investigation, R1 residing in a locked memory care facility with no dementia or mild cognitive impairment diagnosis and is/was residing in a facility that is not compatible with other residents in care, presents an unsafe and vulnerable environment detrimental to all residents including R1. Therefore, the allegation that Staff does not provide a safe environment for a resident is deemed Substantiated at this time.

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. Appeal Rights issued.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250310083615

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: 04/07/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/09/2026 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4) Personal Rights: 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 is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agrees to review personal rights with all staff to include properly managing relationships between residents. Written documentation of training will be submitted directly to LPA via email including description of training, first and last names of trainees, dates and duration of training and name of trainer.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the licensee did not comply with the section cited above when administrator did not protect a safe environment for residents in care resulting in resident(s) being inappropriately touched by another resident which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Administrator agrees to send training documentation directly to LPA via email no later than POC due date (4/9/2026).
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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: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC9099 (FAS) - (06/04)

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