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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802118
Report Date: 04/12/2023
Date Signed: 04/12/2023 01:43:26 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
04/20/2021 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20210420120111
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
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Andrea Katz, AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Residents left in soiled diapers for a long period of time.
Facility staff did not keep the facility premises in clean and sanitary condition at all times.
Facility staff did not keep centrally stored medication locked.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kontilis conducted a subsequent complaint visit to the facility to issue final findings on this complaint. LPA met with Andrea Katz, Administrator and Jovany Guerra, Senior Generations Program Director.
During the investigation, LPA conducted interviews with staff on 4/21/2021 at 3:50 pm, 4/28/2021 at 4:45 pm, 4/29/2021 at 12:50 pm, 3/13/2023 at 1:47 pm, 3/29/2023 10:14 am and 2:55 pm, and 3/30/2023 at 1:15 pm. LPA conducted interviews with a witness on 3/21/2023 at 2:19 pm, and interviews with responsible parties on 4/14/2022 at 4:55 pm. LPA also reviewed relevant documentation.
On the allegation: Residents left in soiled diapers for a long period of time. LPA interviewed a staff, who stated they would arrive on their shift and would find “at least 90%” of the residents in wet/soiled diapers. Staff stated they found one resident “digging” in their diaper and had feces on their hand. Staff stated caregivers on the previous shift would not change the residents. Staff interviewed stated their job is to perform rounds and check on the residents. Staff stated residents are repositioned every 2 to 2.5 hours, are toileted or have their
Please continue to 9099, 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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20210420120111
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: 04/12/2023
NARRATIVE
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briefs checked. Staff stated their job is to change residents’ briefs so that they are dry. Multiple staff stated many times residents would have soiled diapers full of feces that had dried already, indicating it had been a long time since they were changed. Staff indicated sometimes residents had feces on their back or in their pants due to not being changed often enough. Staff stated on one occasion, a resident had it on their hands, body, face, on the bed, on the floor, and stated it was “everywhere.” LPA observed a photograph labeled Room 224 showing a pair of jeans that are soiled with feces. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation: Facility staff did not keep the facility premises in clean and sanitary condition at all times. LPA interviewed staff, who stated staff on other shifts would not clean the facility areas and as a result the facility had a “bad smell.” Staff interviewed stated the floor, walls and toilets were dirty. LPA observed a photograph of a dirty floor in Room 223, showing brown spots on the floor. LPA observed a photograph of the toilet in Room 223, showing feces smeared on the toilet seat. Staff interviewed indicated resident’s rooms were dirty and dusty, the toilets were dirty with urine for multiple days, and the bathroom floor had spots of urine and was not cleaned timely. Staff interviewed indicated feces was also on the floor, and it would just be wiped and not deep cleaned. Responsible parties interviewed indicated resident rooms smelled of urine, the floor under resident beds was dirty and had trash, and the bathroom floor was dirty and sticky from urine. Responsible parties indicated they cleaned resident’s rooms on a few occasions due to the condition. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation: Facility staff did not keep centrally stored medication locked. It was alleged that a medication was found on the counter of Room 220. LPA was provided a photograph showing a clear plastic cup filled with a brown liquid. There is no scale to the photo, but the cup appears to be a clear plastic drinking glass of at least 8 ounces. LPA was unable to determine if the cup contained medication or not, but it does not appear to be medication. Staff interviewed stated medications were kept locked. Witness interviewed indicated they were not aware of the medications being unlocked around the time of this complaint. One staff stated sometimes the medication room door was unlocked.
During today’s visit at approximately 11:39 am, LPA observed the unlocked medication cart was unattended in the common area near several residents who were participating in an activity. LPA observed two residents walking near the medication cart. At the time of LPA's observation, Staff 1 (S1) approached the medication cart. S1 stated “I could have sworn the medication cart was locked."


Please continue to 9099-C, Pg 3.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20210420120111
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: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2023
Section Cited
CCR
87468.2(a)(4)
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…Residents…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. This requirement was not met as evidenced by:
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Administrator agrees to conduct staff training with care staff (med techs, caregivers, duty aides) for incontinence care. Training to include date(s), Trainer's full name, title, description of training w/training roster with full name and signature of each trainee.
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Based on interviews, the licensee did not ensure resident’s incontinence care needs were met, which posed a potential health and safety risk to residents in care.
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Type B
04/17/2023
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
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Administrator agrees to provide a written statement acknowledging CCR 87303 in its entirety.
Administrator agrees to provide facility's housekeeping schedule for April 12 through April 30, 2023.
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Based on interviews, the licensee did not ensure the rooms and bathrooms were clean from urine and feces, which posed 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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20210420120111
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: 04/12/2023
NARRATIVE
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Based on the information obtained, the allegation is deemed Substantiated at this time. LPA recommends the Administrator remind all staff that the medications need to be locked at all times.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted. Deficiencies cited on 9099-D. 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: 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20210420120111
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: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2023
Section Cited
CCR
87465(h)(2)
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87465(h)(2) Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
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Administrator agrees to in-service training for protocol and regulation to keep the medication cart and medication room locked at all times. Training will be conducted by J. Guerra, Senior Generations Program Director and will include date(s) training was conducted, description of training, first and last names of trainees with signatures.
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Based on observation, the licensee did not comply with the above cited section when LPA observed the medication cart was unlocked and unattended, 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: 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5