<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802118
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:32:25 PM


Document Has Been Signed on 04/21/2022 04:32 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: 243DATE:
04/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jovany Guerra, Generations Program DirectorTIME COMPLETED:
02:45 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) Olson and Kontilis conducted an unannounced visit to the facility. While investigating complaint # 29-AS-20210614172310, LPA Kontilis noted the following deficiencies.

Resident 1 (R1)’s care plan was not updated timely after multiple changes in condition. R1 sustained sixteen falls in five months. Records obtained do not indicate R1’s care plan was updated after the first thirteen falls, and was only updated on 5/21/2020 and 5/22/2020. After the fall on 2/26/2020, R1 was diagnosed with a dislocated hip. Medical records indicate R1 was provided a knee immobilizer/brace and was discharged the next day back to the facility. Medical records instruct R1 to wear the knee immobilizer at all times for one week, until R1 follows up with an orthopedic surgeon. R1’s care plan was not updated to include these new instructions from the hospital regarding the knee immobilizer/brace. After the fall on 5/21/2020, R1 was again diagnosed with a dislocated hip following the witnessed fall on 5/20/2020. Medical records indicate a knee immobilizer/brace was placed on R1 and “staff at Oak Cottage notified of plan of care.” Instructions indicate to use the knee immobilizer for a few days to prevent recurrent dislocations. R1 was also given a wedge pillow from the hospital and instructions to use it to keep R1’s legs from being crossed. R1’s care plan was not updated to include the knee immobilizer/brace nor the wedge. In the facility’s Progress Notes, there are multiple entries showing R1 did not have the wedge in place and R1 kept removing the wedge. On 5/26/2020, Progress Notes indicate at 2:00am, R1 was observed with the wedge not in place and the leg brace was on incorrectly according to S4. Progress Notes indicate S4 showed S7 the correct way to put the brace on and how to place the wedge. In addition, on 2/11/2020 R1 was noted to be “anxious pacing up and down the halls and exit seeking” and on 2/22/2020, R1 continued exit seeking behavior but R1’s care plan was not updated to indicate this new behavior. On 2/23/2020, staff noted R1 was “in wheelchair most of the day to avoid falls.” R1’s physician’s report was not updated to indicate R1 was using a wheelchair nor to indicate exit seeking behavior. Based on the information obtained, the facility did not update R1’s care plan after multiple changes in condition.
Continued on 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
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)
Page: 1 of 3


Document Has Been Signed on 04/21/2022 04:32 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: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2022
Section Cited
CCR
87463(a)

1
2
3
4
5
6
7
87463(a) Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
GPD agrees to provide a written statement of understanding of section 87463 by 4/26/2022.
8
9
10
11
12
13
14
Based on interviews and record review, the facility did not ensure R1’s appraisal was updated to reflect significant changes, which posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Request Denied
Type B
04/26/2022
Section Cited
CCR87705(d)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia. In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
GPD agrees to implement a plan to increase room checks for residents to ensure residents do not have access to unsafe items. GPD will send a copy of the plan by 4/26/2022.
8
9
10
11
12
13
14
Based on observation, the facility did not ensure residents with dementia did not have access to an electric tea kettle, which posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3


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
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
26
27
28
29
30
31
32
During a tour related to the complaint on 4/19/2022, LPA Kontilis observed an electric tea kettle plugged in Room # 213. Generations Program Director (GPD) removed the tea kettle from the room during the visit at 2:46pm.

Exit interview, deficiencies cited on 809-D, report emailed, appeal rights emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
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)
Page: 2 of 3