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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802118
Report Date: 04/12/2023
Date Signed: 04/12/2023 01:50:23 PM


Document Has Been Signed on 04/12/2023 01:50 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 CAREFACILITY NUMBER:
425802118
ADMINISTRATOR:ANDREA KATZFACILITY TYPE:
740
ADDRESS:1820 DE LA VINA STREETTELEPHONE:
(805) 456-7270
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:50CENSUS: 36DATE:
04/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Andrea Katz, AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20210420120111 investigation visit conducted on 4/12/2023. LPA met with Andrea Katz, Administrator and Jovany Guerra, Senior Generations Program Director.

Upon record review and interviews conducted, LPA determined CCL received no notifications of approximately 15 residents who were placed on hospice from 1/20/2022 through 1/13/2023. The facility currently has a hospice care waiver of 20. There are 10 residents currently receiving hospice services at this time.

LPA counseled Administrator Katz on the importance of following the requirements in California Code of Regulations (CCR) 87632 Hospice Care Waiver. LPA recommended Administrator Katz review CCR 87632 in its entirety to determine if the facility can adhere to the CCR hospice care waiver requirements.

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. Deficiencies cited. Copy of report and Appeal Rights issued.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
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 04/12/2023 01:50 PM - 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: OAK COTTAGE OF SANTA BARBARA MEMORY CARE
FACILITY NUMBER: 425802118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2023
Section Cited

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87632(d)(2) Hospice Waiver: The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services.
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Administrator agrees to conduct training with all staff responsible for submitting hospice notification. Training records will show full names of attendees, date of training, and person conducting training with first and last names in print and signature.
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This requirement is not met as evidenced by:
Based on records review, the licensee did not comply with the section cited above as CCL did not receive hospice notifications for approximately 15 residents placed on hospice from 1/20/2022 to 1/31/2023 which poses a potential 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: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
LIC809 (FAS) - (06/04)
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