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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802118
Report Date: 09/24/2024
Date Signed: 09/24/2024 06:10:40 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
09/17/2024 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20240917144445
FACILITY NAME:OAK COTTAGE OF SANTA BARBARA MEMORY CAREFACILITY NUMBER:
425802118
ADMINISTRATOR:TYLER BARNESFACILITY TYPE:
740
ADDRESS:1820 DE LA VINA STREETTELEPHONE:
(805) 456-7270
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:50CENSUS: 34DATE:
09/24/2024
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Tyler Barnes, AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility staff did not provide adequate supervision to residents in care.
Illegal eviction.
Facility staff did not properly report abuse.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an initial complaint visit for this investigation. During today’s visit, LPA met with Tyler Barnes, Administrator, and explained the purpose of the visit. LPA toured the facility, interviewed staff, and obtained relevant documents.

On the allegation: Facility staff did not provide adequate supervision to residents in care. R1 was admitted into the facility for respite care on 8/20/2024. Based on R1’s aggressive behaviors, the need for a one-on-one private caregiver for R1 was implemented at the time of admission on 8/20/2024. CCL received incident reports from the facility reporting aggression from R1 on 8/26/2024, 8/27/2024, and 8/29/2024. Based on the incident report and interviews conducted, on 8/29/2024 at approximately 4:45 pm, R1 and R2, both of whom had private one-on-one caregivers, were in the elevator. When the elevator door opened, R1 grabbed R2’s hair, and walked R2 out of the elevator into the activity room while keeping their hair in grip. Facility staff observed the abuse and intervened to separate the residents. No injuries were noted.
Please continue to 9099-C, Pg 2.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
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-20240917144445
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: OAK COTTAGE OF SANTA BARBARA MEMORY CARE
FACILITY NUMBER: 425802118
VISIT DATE: 09/24/2024
NARRATIVE
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It was noted during interviews that R1’s one-on-one caregiver did not speak English and could not effectively communicate with the resident. Although the facility had implemented one-on-one supervision for R1 due to their known aggressive behaviors, the one-on-one staff was unable to prevent R1 from abusing another resident and could not redirect R1 to release R2’s hair. Interviews with Staff 1 (S1) revealed R1 had a strong grip on R2 leading R2 to an area adjacent from the area approximately 64 feet from where the incident first occurred. Staff stated this likely hurt R2 although Staff stated that after the incident R2 had a look on their face as though that they were in “shock” and R2 was holding the back of their head indicating they were in pain.” Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation: Illegal eviction. The SOC341 for the 8/29/2024 incident states R1 was picked up by their POA on 8/29/2024 at approximately 6:00 pm and R1 was discharged from the facility on 8/30/2024 due to the community being unable to meet R1’s needs. It was clarified through interview that after the incident on 8/29/2024, Executive Director Tyler Barnes through the Interim LVN Nurse Consultant directed LVN Consultant to contact facility staff to let R1’s responsible party know that R1 needed to be picked up within the next few hours or 9-1-1 would be called and R1 would be transported to the hospital and evaluated for “altered state of mind and return to baseline due to aggression and refusing medications". On 8/30/2024, Executive Director stated POA was notified via telephone that due to multiple aggressions and multiple medication refusals, that R1 is not appropriate to the community, poses risk to residents and staff because R1 is refusing the medications, and the respite is ended as 8/30/2024. Executive Director stated R1’s responsible party was not provided a written notice and provided additional resources available during the phone call. CCL received no written notice of eviction for R1 and it was confirmed R1’s POA did not receive any written notice of the eviction. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation: Facility staff did not properly report abuse. The facility submitted a self-reported incident report for R1 and R2 for an incident that occurred on 8/28/2024 at approximately 4:45 pm. The SOC341 abuse reporting form states it was sent to the local Ombudsman office and CCL on 9/5/2024. Further investigation revealed it was not faxed to the local Ombudsman office until 9/7/2024 at 10:40 am, and CCL has no record of receiving this SOC341.

Please continue to 809-C, Pg 3.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20240917144445
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: OAK COTTAGE OF SANTA BARBARA MEMORY CARE
FACILITY NUMBER: 425802118
VISIT DATE: 09/24/2024
NARRATIVE
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The facility could not provide proof that the SOC341 was submitted to CCL. This did not meet the 24-hour reporting timeframe requirement per AB 1417 and CCR 87211(c), and which are also listed in the instructions of the SOC341 form. Additionally, another SOC341 for an incident occurring on 8/31/2024 also was not sent to the Ombudsman office until 9/7/2024. CCL received the incident report for this incident via email at 9/7/2024 at 6:00 pm but no SOC341 was received by CCL. Based on the information obtained, the allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

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

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20240917144445
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: OAK COTTAGE OF SANTA BARBARA MEMORY CARE
FACILITY NUMBER: 425802118
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/26/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Personal Rights…Residents in privately operated residential care facilities for the elderly shall have all of the following 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.
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Administrator agrees to provide training to all staff on supervision requirements, with special emphasis on redirecting residents and mitigating resident on resident conflict. Administrator will schedule the training by 9/26/2024 and provide proof of completed training by 10/9/2024.
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This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited when staff did not provide adequate supervision to R1 resulting in aggressive incidents, which posed an immediate health and safety risk to residents in care.
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Request Denied
Type A
09/26/2024
Section Cited
CCR
87224(c)
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87224(c) Eviction Procedures. The licensee shall, in addition to either serving the required 30 days’ notice…or seeking approval from the Department and service 3 days’ notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person. This requirement was not met as evidenced by:
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Administrator agrees to provide a written, signed statement of understanding and acknowledgement of section 87224 Eviction Procedures by 9/26/2024.
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Based on interviews and record review, the licensee did not comply with the section cited when they issued a verbal eviction for R1 to be removed from the facility, which posed 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20240917144445
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: OAK COTTAGE OF SANTA BARBARA MEMORY CARE
FACILITY NUMBER: 425802118
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/26/2024
Section Cited
CCR
87211(c)
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87211(c) Reporting Requirements: Any suspected physical abuse that does not result in serious bodily injury...shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required…This requirement is not met as evidenced by:
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Administrator agrees to schedule vendorized training on reporting requirements and AB 40 for all staff and inform LPA of vendor information and scheduled date by 9/26/2024. Proof of completed training to be submitted to CCLD by 10/9/2024.
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Based on interviews and record review, the licensee did not comply with the section cited above when staff did not report resident on resident abuse for 11 days, which posed 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5