425802118-4-21-2022-29-AS-KKOS-CDPW2T-20220421165451

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802118
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:55:08 PM

Document Has Been Signed on 04/21/2022 04:55 PM - 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:	OAK COTTAGE OF SANTA BARBARA MEMORY CARE		FACILITY NUMBER:	425802118
ADMINISTRATOR:	ANDREA KATZ		FACILITY TYPE:	740
ADDRESS:	1820 DE LA VINA STREET		TELEPHONE:	(805) 456-7270
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY:	50	CENSUS: 43	DATE:	04/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Jovany Guerra, Generation Program Director		TIME COMPLETED:	04:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Jeannette Olson and Kristin Kontilis conducted an unannounced on-site one-year infection inspection control visit to the above-named facility. LPAs began the inspection at 2:30 pm. A Mitigation plan has been submitted to CCLD. LPAs met with Jovany Guerra, Generations Program Director. Administrator Andrea Katz was not available at the time of the inspection. LPAs explained the purpose of the visit. The facility is a two-story secured perimeter Residential Care Facility for the Elderly (RCFE). There are currently 43 residents in care with a Dementia diagnosis. Currently, there are eleven (11) residents on hospice. The facility has submitted a Mitigation Plan to the Department. The facility has an entry station at the front door of the facility. Upon entry, staff, visitors, and clients who are returning from an outing are required to sign-in, and have a temperature screening. All documentation is kept in a locked filing cabinet in the Administration office located on the first floor of the facility. Screening documentation is stored in the facility basement. Bulk supplies of PPE gear, hand sanitizer, disinfecting wipes, disinfecting spray, gloves, and masks are kept in the facility basement. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. The facility was seen to be in good repair inside and outside. Fire inspection was conducted on 5/10/2021. There are five (5) fire extinguishers. Each resident's room has a dual smoke alarm and carbon monixide detector. First Aid kits are kept in the Medication area of the Nurse's station on Floor 2, the kitchen and reception area on Floor 1. LPA observed the kitchen cabinets, refrigerator, and stove are clean. There is a sufficient amount of 2-days of perishable and 7 days of non-perishable foods. Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

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: OAK COTTAGE OF SANTA BARBARA MEMORY CARE	FACILITY NUMBER: 425802118
	VISIT DATE: 04/21/2022

NARRATIVE

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Residents participate at will in activities such as but not limited to exercise classes, pet therapy, nature walks, puzzles, games, Happy Hour, virtual travel tours, excursions to local eateries, and scenic rides. Residents are assisted with Assisted Daily Living (ADLs) needs such as toileting, bathing, showering, eating, feeding, transferring, laundry tasks, light housekeeping, and medication administration.
The front are of the facility consists of a patio for visitation, concrete steps, concrete ramps and concrete walkways. The back patio has a barbeque and outdoor furniture conducive for visitation.
The facility has 40 resident rooms. There are 4 shared bedrooms and 7 shared bathrooms. Each bedroom has a bed, nightstand, and lights to provide sufficient lighting.
All staff associated with the facility have criminal record clearance.

Exit interview conducted. Copy of report emailed. No deficiencies noted.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC809 (FAS) - (06/04)

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