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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802118
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:53:01 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
06/14/2021 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20210614172310
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: 43DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jovany Guerra, Generations Program DirectorTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Due to staff neglect, resident suffered multiple falls resulting in injury.
Facility staff did not meet Resident’s needs.
Facility staff did not observe Resident's change of condition.
Facility did not keep resident's room clean.
Facility did not provide resident necessary toiletries.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Jeannette Olson and Kristin Kontilis conducted a subsequent complaint visit to issue final findings on the above-stated allegations. LPAs met with Jovany Guerra, Generations Program Director and explained the purpose of the visit. During the investigation, LPA Kotilis toured the facility on 6/22/2021 at 12:00 pm, interviewed the administrator at 11:23 am, interviewed the marketing director at 12:15 pm. LPA Kontilis also obtained copies of relevant documents. Medical records for R1 were subpoenaed on 10/18/2021. LPA Kontilis conducted additional interviews with staff on 4/12/2022 between 12:30 pm and 4:30 pm. LPA Kontilis conducted interviews with residents' responsible parties on 6/21/2021, on 4/14/2022 between 1:00 to 5:00 pm, and on 4/19/2022 at 8:08 am. LPA Kontilis toured the facility on 4/19/2022 at 1:30 pm and on 4/20/2022 at 11:40 am. LPA Kontilis interviewed Marketing Director and Generations Program Director during the visit on 4/20/2022.
On the allegation: Due to staff neglect, resident suffered multiple falls resulting in injury. LPA Kontilis reviewed documents including R1’s physician’s report, pre-admission appraisal, assessment/care plan, incident reports, and a resident incident/accident log. R1’s physician’s report dated 10/7/2019 indicates R1
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: 04/21/2022
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 14
Control Number 29-AS-20210614172310
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: 04/21/2022
NARRATIVE
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has chronic traumatic encephalopathy, Alzheimer’s dementia, hypertension, is ambulatory, and ambulates without assistance.
R1’s pre-placement appraisal dated 11/10/2019 indicates R1 is “a bit unsteady”; indicates R1 could slowly climb stairs if grab bars were available; indicates R1 is able to walk without any physical assistance including walker, crutches, or another person, or is able to walk independently with a cane; also indicates “sometimes” R1 is unable to walk independently with just a cane; indicates R1 uses a wheelchair but does not use a walker (contrary to physician’s report); and R1 does not need assistance moving about the facility. The pre-placement appraisal indicates R1 can transfer independently in and out of bed and can dress self, but a note was made R1 “is slow but can do it”; R1 could also toilet independently, and notes indicate “Can do. Usually! Well!”; R1 needs assistance with bathing, though another section indicates R1 only needs staff to “encourage” R1 to shower. The pre-placement appraisal indicates R1 needed observation at night to check their status.
R1’s assessment completed by Jovany Guerra, Generation Program Director, on 11/12/2019 indicates R1 requires reminders to complete daily grooming; requires one staff assistance for bathing; indicates R1 has a prior history of falls within 6 months; indicates R1 does not have impaired functional mobility; indicates R1 has incontinence (contrary to physician’s report); indicates R1 did not require 1:1 care due to behaviors; and notes R1 uses a walker while ambulating (contrary to physician’s report and pre-placement appraisal). Updates to R1’s assessment include on 11/21/2019, vision assistance was needed with activities, reading mail, identifying objects; a shower chair was added; dressing assistance was required twice a day; grooming assistance was required; and status checks every 2 hours day and night were required. The assessment was updated again on 5/21/2020 to indicate R1 had a history of hip dislocations, and was updated again on 5/22/2020 to indicate R1 uses a wheelchair when being escorted to and from room.
Incident Reports and Residence Incident/Accident log indicate R1 sustained falls on 1/6/2020 at 7:00 pm (fall); 2/9/2020 at 10:04 am (found lying on ground); on 2/9/2020 at 6:00 pm (fall); on 2/12/2020 at 3:00 am (found lying on ground); on 2/20/2020 at 2:00 am (fall); on 2/23/2020 at 3:45 am (fall); on 2/24/2020 at 5:15 pm (fall); on 2/26/2020 at 8:30 pm (transported to hospital); on 3/26/2020 at 8:50 pm (fall); on 4/20/2020 at 4:35 pm (fall); on 4/25/2020 at 11:05 am (fall); on 5/9/2020 at 9:00 pm (fall); on 5/19/2020 at 5:40 pm (fall); on 5/20/2020 at 6:00pm (transported to hospital); on 5/21/2020 at 5:15am (transported to hospital); and on 5/27/2020 at 9:40 am (found lying on ground). Overall, 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.
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: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 9 of 14
Control Number 29-AS-20210614172310
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: 04/21/2022
NARRATIVE
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 Progress Notes indicate on 2/9/2020, staff noted R1 had been “very unsteady lately” but the care plan was not updated. On 2/11/2020, R1 was noted to be “anxious pacing up and down the halls and exit seeking” but R1’s care plan was not updated to indicate this new behavior. 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.
The fall on 2/09/2020 required first aid for a skin tear on the right knee. After the fall on 2/20/2020, R1 went to the hospital where R1 was diagnosed with a dislocated hip. Medical records for 2/20/2020 indicate R1 had an unwitnessed fall and complained of hip pain, and confirm R1 sustained a dislocated hip. The fall on 2/24/2020 required first aid for rug burns sustained to the forehead and right knee. After the fall on 2/26/2020, R1 complained of right leg pain and was sent to the hospital, where R1 was diagnosed with another dislocated hip, as confirmed by medical records. 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. The fall on 4/20/2020 required first aid for carpet burns sustained on their right knee. After the fall on 5/21/2020, R1 went to the hospital. Medical records confirm 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 hospital staff noted “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 S6 the correct way to put the brace on and how to place the wedge.
Based on the information obtained, the facility did not appropriately update R1’s physician’s report or care plan after R1 experienced changes in condition. R1 sustained multiple falls, including three resulting in an injury of a dislocated hip, two resulting in carpet/rug burns, and one that resulted in a skin tear. R1 was discharged from the hospital with instructions to use a knee immobilizer/brace and wedge, but staff did not
Please continue to 9099-C, Pg 4.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 10 of 14
Control Number 29-AS-20210614172310
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: 04/21/2022
NARRATIVE
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use the knee immobilizer and wedge properly on at least one occasion. R1 also demonstrated exit-seeking behavior, but the physician’s report and care plan were not updated to indicate the behavior. It has been determined R1 sustained multiple falls and injuries. No evidence was obtained to indicate the facility attempted to meet R1’s needs by mitigating R1’s falls for the first thirteen falls sustained. Based on the information obtained, the allegation is deemed Substantiated at this time. A $500 immediate civil penalty for injury of a resident as the result of a deficiency is assessed today. The administrator was informed that additional civil penalties may be assessed based on Health and Safety Code 1569.49(f).
On the allegation: Facility staff did not meet Resident’s needs. Responsible Party 1 (RP1) stated on 1/1/2020, RP1 visited R1 for the first time since R1 moved in to the facility on 11/21/2019. RP1 stated R1 appeared to be unkempt, needed a haircut, and was in dirty clothes. On 5/27/2020, RP1 was notified R1’s needs had increased and R1 needed 1:1 care. After 5/27/2020, RP1 provided 1:1 care to R1. RP1 stated RP1 gave R1 a sponge bath, cut R1’s nails because they were long, and shaved R1. LPA reviewed a shower schedule from 2020 and observed R1 was scheduled for a shower on 5/29/2020, after R1 had a 1:1 caregiver. S4 stated they felt R1’s hygiene needs were not met, along with other residents. During an interview, Generations Program Director (GPD) Jovany Guerra stated the shower schedule obtained was only a schedule and was not confirmation the showers happened as scheduled. Based on this information, facility staff did not meet R1’s hygiene and grooming needs. On 5/28/2020, RP1 suspected R1 had a Urinary Tract Infection (UTI) due to frequent urge to urinate. According to RP1, RP1 tried to find staff to assist R1 with toileting but could not find any staff. RP1 then assisted R1 to the bathroom fourteen times, due to the frequent urge to urinate. RP1 collected a urine sample because no staff could be found to assist. GPD Guerra stated the purpose of R1’s 1:1 was to provide additional supervision to try to prevent R1 from falling. During the interview, GPD stated in the past they had issues with facility staff believing they did not need to provide Activities of Daily Living (ADL) care to residents who had a 1:1 caregiver. GPD stated he addressed this concern with staff during an in-service training and clarified that facility staff must still meet the residents’ needs and provide care and supervision to residents for all matters including ADLs. GPD also clarified 1:1 caregivers are intended only for companionship and additional supervision. Based on this information, the facility staff did not meet R1’s toileting needs. On 5/21/2020, R1 was discharged from the hospital after sustaining a fall and dislocated hip. R1 was given a leg immobilizer/leg brace and was instructed to wear it for a “few days.” R1 was also provided a wedge pillow to position R1’s legs. R1’s care plan was not updated to include the leg immobilizer or wedge as part of R1’s care plan. On 5/26/2020, Progress Notes indicate at 2:00 am, R1 was observed with the wedge not in place and the leg brace was on incorrectly according to S4. Progress Notes indicate S4 showed Please continue to 9099-C, Pg 5.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 11 of 14
Control Number 29-AS-20210614172310
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: 04/21/2022
NARRATIVE
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S6 the correct way to put the brace on and how to place the wedge. R1’s needs were not met when staff put the leg brace on R1 incorrectly. R1 requiring 1:1 care for falls did not absolve the facility of their responsibility to provide care and supervision to R1 as outlined in R1’s care plan. In addition, R1’s care plan was not updated to include the leg immobilizer and wedge, and staff put on R1’s leg brace incorrectly. Therefore, based on the evidence obtained, the allegation is deemed Substantiated at this time.
On the allegation: Facility staff did not observe Resident's change of condition. R1’s physician’s report dated 10/7/2019 indicates R1 does not have bladder or bowel impairment, and cares for their own toileting needs. On 11/21/2019 the care plan was updated to include transfer assistance with one staff, use of a toilet riser, and notes that R1 “requires assistance for toileting and escort.” Progress notes indicate staff provided R1 assistance with toileting or changed R1’s brief. R1’s care plan had been updated 11/21/2020 to indicate R1 required status checks every 2 hours day and night. On 5/27/2020, RP1 was notified R1’s needs had increased and R1 needed 1:1 care. After 5/27/2020, RP1 provided 1:1 care to R1. On 5/28/2020, RP1 suspected R1 had a UTI, but RP1 was unable to obtain a urine sample because R1 could not produce enough urine to sample. RP1 obtained a urine sample on 5/29/2020 and provided it to Staff 3 (S3). RP1 stated they observed a courier pick up the sample that afternoon. Progress notes from 5/29/2020 at 8:48pm indicate R1 had the urge to urinate frequently and R1’s doctor was informed and a urine sample was requested. According to RP1, S3 stated they had obtained an antibiotic for R1. On 5/30/2020, R1 continued to have bladder and back pain, and had frequent urination. RP1 asked Staff 5 (S5) about the antibiotic, and S5 confirmed they did not have an antibiotic for R1 and no antibiotics were listed on R1’s med sheet. RP1 called R1’s physician and described R1’s symptoms including frequent urination and back pain. R1’s physician prescribed an antibiotic for R1. RP1 then picked up the prescription from CVS pharmacy. Facility’s plan of operation, page 12, indicates the assisted living director or designee will immediately notify the physician by phone if a resident experiences a change in condition. The plan of operation also states the physician recommendations will be followed and this information will be documented and kept on file at the community. GPD Guerra stated the purpose of R1’s 1:1 was to provide additional supervision to try to prevent R1 from falling. During the interview, GPD stated in the past they had issues with facility staff believing they did not need to provide Activities of Daily Living (ADL) care to residents who had a 1:1 caregiver. GPD stated he addressed this concern with staff during an in-service training and clarified that facility staff must still meet the residents’ needs and provide care and supervision to residents for all matters including ADLs. GPD also clarified 1:1 caregivers are intended only for companionship and additional supervision. Facility staff did not
Please continue to 9099-C, Pg 6.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 12 of 14
Control Number 29-AS-20210614172310
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: 04/21/2022
NARRATIVE
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contact R1’s physician about the change in condition and did not obtain the medication that was ordered. Instead RP1 contacted R1’s physician about the change in condition and obtained the ordered medication. R1 requiring 1:1 care for falls did not absolve the facility of their responsibility to provide care and supervision to R1, including observation of the resident for changes in condition and ensuring R1 received timely medical attention for the suspected UTI. Therefore, based on the evidence obtained, the allegation is deemed Substantiated at this time.
On the allegation: Facility did not keep resident's room clean. RP1 stated R1’s floor was dirty under the bed, the room smelled of urine, and candy wrappers were observed on the floor under and behind furniture. LPA observed photos provided by RP1 and observed seven pieces of paper or tissue wadded up on the ground, between a nightstand and the wall, next to the bed. LPA also observed another photo showing shoes on the ground along with two tissues. S4 stated R1’s clothes and shoes were often not where they were supposed to be. Responsible Party 2 (RP2) stated Resident 2 (R2)’s room smelled of urine, and the bathroom floor was dirty and sticky from urine. RP2 stated RP2 cleaned R2’s room on a few occasions due to the condition. S4 stated residents’ 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. On 4/19/2022, LPA toured the facility with Generations Program Director. At 2:14 pm, LPA observed room 219 had a strong odor of urine. At 2:22 pm GPD requested housekeeping to attend to the urine in the room. Based on the information obtained, the allegation is deemed Substantiated at this time.
On the allegation: Facility did not provide resident necessary toiletries. RP2 stated on at least three different occasions, they had to ask staff for toilet paper for R2’s room because there was none. RP1 stated they observed R1’s bathroom was lacking toilet paper on 1/1/2020. On 4/19/2022, LPA Kontilis toured the facility and observed no toilet paper on the toilet paper holder, nor anywhere else in the bathroom shared by Rooms 210 and 211. LPA photographed the empty toilet paper holder. LPA observed toilet paper on the counter of Room 210 and observed no toilet paper on the counter of Room 211. The counter where toilet paper was observed in Room 210 was not within reach of the toilet and is separated by a door. Based on the information obtained, the allegation is deemed Substantiated at this time.

Exit interview conducted. Copy of report emailed. Deficiencies cited on 9099-D. Civil penalty issued. Appeal rights issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 8 of 14
Control Number 29-AS-20210614172310
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: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/26/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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GPD agrees to provide a written plan, including but not limited to detailing how the facility will meet the needs of residents requiring care and supervision services related to fall risks, residents requiring 1:1 care, and changes in condition. GPD will submit plan to CCL by 4/26/2022, due to administrator being out of the facility.
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Based on interviews and record review, the licensee did not ensure R1 was accorded safe, healthful and comfortable accommodations due to the numerous falls and injuries sustained, which posed an immediate health and safety risk to residents in care.
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CIVIL PENALTY ASSESSED
Request Denied
Type A
04/26/2022
Section Cited
CCR
87468.2(a)(4)
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…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. This requirement was not met as evidenced by:
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GPD agrees to provide a written plan, including but not limited to detailing how the facility will meet the needs of residents requiring care and supervision services related to fall risks, residents requiring 1:1 care, and changes in condition. GPD will submit plan to CCL by 4/26/2022, due to administrator being out of the facility.
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Based on interviews and record review, the licensee did not ensure R1 received care, supervision, and services to meet R1’s needs, 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: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 13 of 14
Control Number 29-AS-20210614172310
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: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/26/2022
Section Cited
CCR
87466
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87466 Observation of the Resident. The licensee shall ensure…residents are regularly observed for changes in physical, mental, emotional…social functioning…appropriate assistance is provided when…observation reveals unmet needs...changes such as...deterioration of...physical health condition are observed, the licensee shall ensure that…changes are documented…brought to the attention of the resident's
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GPD agrees to hold an in-service training with caregivers and med-techs on recognizing changes in condition and the facility’s policy/procedure regarding a change in condition. GPD will submit training log to include time and date of training, and attendees (printed/signed) to CCL by 4/26/2022, due to administrator being out of the facility.
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physician…the resident's responsible person...This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure R1 was observed for changes in condition and R1’s physician was notified timely, which posed an immediate health and safety risk to residents in care.
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Request Denied
Type B
04/26/2022
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. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
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GPD agrees to hold in-service training to provide expectations to housekeepers, and to remind caregivers they should promptly notify housekeeping when additional room cleaning is needed. GPD will submit training log to include time and date of training, and attendees (printed/signed) to CCL by 4/26/2022.
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Based on interviews, the licensee did not ensure the rooms and bathrooms of R1 and R2 were clean from urine and debris, 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: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 14
Control Number 29-AS-20210614172310
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: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/26/2022
Section Cited
CCR
87307(a)(3)(D)
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87307(a)(3)(D) Personal Accommodations and Services: …The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: Hygiene items of general use such as soap and toilet paper. This requirement was not met as evidenced by:
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LPA observed basic hygiene items in each bathroom during the visit on 4/20/2022. POC cleared during visit.
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Based on interviews, the licensee did not ensure toilet paper was provided to 2 out of 2 residents (R1, R2), which posed a potential health and personal rights 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: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 14
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
06/14/2021 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20210614172310

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: 43DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jovany Guerra, Generations Program DirectorTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Facility staff did not properly assist resident with medications.
Facility staff gave Resident/Resident’s Responsible Party a verbal 24-hour eviction notice.
Facility did not allow Resident(s) to have visitors.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to issue final findings on the allegations stated above. LPA met with Generations Program Director Jovany Guerra and explained the purpose of the visit. During the investigation, LPA toured the facility on 6/22/2021 at 12:00 pm, interviewed the administrator at 11:23 am, interviewed the Marketing Director at 12:15 pm. LPA also obtained copies of relevant documents. Medical records for R1 were subpoenaed on 10/18/2021. LPA conducted additional interviews with staff on 4/12/2022 between 12:30 pm and 4:30 pm. LPA conducted interviews with resident responsible parties on 6/21/2021, on 4/14/2022 between 1:00 to 5:00pm, and on 4/19/2022 at 8:08 am. LPA toured the facility on 4/19/2022 at 1:30 pm and on 4/20/2022 at 11:40 am. LPA interviewed Marketing Director and Generations Program Director on 4/20/2022 during the visit.
On the allegation: Facility staff did not properly assist resident with medications. LPA reviewed Medication Administration Records (MAR) for R1 for November 2019 through June 2020. On 5/27/2020, RP1 was notified R1’s needs had increased and R1 needed 1:1 care. After 5/27/2020, RP1 provided 1:1 care to R1. On
Please continue to 9099-C, Pg 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 14
Control Number 29-AS-20210614172310
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: 04/21/2022
NARRATIVE
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5/28/2020, RP1 suspected R1 had a UTI, but RP1 was unable to obtain a urine sample because R1 could not produce enough urine to sample. RP1 obtained a urine sample on 5/29/2020 and provided it to Staff 3 (S3). RP1 stated they observed a courier pick up the sample that afternoon. According to RP1, S3 stated they had obtained an antibiotic for R1. On 5/30/2020, R1 continued to have bladder and back pain, and had frequent urination. RP1 asked Staff 5 (S5) about the antibiotic, and S5 confirmed they did not have an antibiotic for R1 and no antibiotics were listed on the med sheet. RP1 called R1’s physician and described R1’s symptoms including frequent urination and back pain. R1’s physician prescribed an antibiotic for R1 over the phone and sent the order to a local pharmacy. RP1 then picked up the prescription from CVS pharmacy. LPA observed the antibiotic listed on R1’s MAR for June 2020. The MAR shows the medication order was effective starting on 5/31/2020 and it is recorded R1 received a dose on 6/1/2020, before moving from the facility. An interview with Generations Program Director (GPD) Jovany Guerra revealed when a new medication is ordered for a resident, the facility’s procedure is to contact the resident’s typical pharmacy and ask it to be filled. GPD stated most residents use the Omnicare pharmacy through CVS, which delivers three times per day to the area. For urgent medications that must be started as soon as possible, the facility is able to contract with the local CVS pharmacy for the medication to be delivered quickly. GPD also stated sometimes family members prefer to fill the prescriptions and bring them directly to the facility. RP1 obtained the antibiotic for R1 to ensure the medication was provided timely to R1. Based on the information obtained, there is not sufficient evidence to prove that the facility did not properly assist R1 with medications. Therefore the allegation is deemed Unsubstantiated at this time. Facility was advised that as a best practice, to ensure adequate communication with responsible parties at all times, particularly when a resident has a newly ordered medication.
On the allegation: Facility staff gave Resident/Resident’s Responsible Party a verbal 24-hour eviction notice. Administrator stated they have never had to serve an eviction notice. Administrator stated they have given verbal notices. Administrator stated if a resident needs a higher level of care, they discuss relocating and give the families “a couple of days or weeks.” Administrator stated “we give it” by telephone or face to face, and again reiterated it is usually a verbal discussion. Administrator stated we have asked family members to find one-on-one care. RP1 stated the facility verbally told RP1 that R1 needed a higher level of care, and needed a 1:1 caregiver or would need to move out. The facility provided R1’s responsible party with an alternative to incurring the considerable expense of having R1 receive 1:1 care as provided for in R1’s admission agreement. Although this cannot be considered a 24-hour verbal eviction notice, this would be considered a
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: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 14
Control Number 29-AS-20210614172310
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: 04/21/2022
NARRATIVE
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a verbal 24-hour eviction notice, this would be considered a change in R1’s level of care needed. The facility should have provided RP1 a 2-day written notice about the increased care needs. The 2-day written notice shall include an explanation as to why a 1:1 caregiver was needed and that RP1 had the choice for the facility to provide a 1:1 staff at a prescribed rate or RP1 could hire their own 1:1. The facility’s plan of operation Residence and Care Agreement, page 9, states “If it is determined by the Community staff that you are a danger to yourself or others, you may be required to receive one-on-one care and supervision for an additional charge as set forth in Appendix A, or for the cost of all services provided by Outside Provider and billed directly to you.” In addition, the facility should have issued a proper, written eviction notice if they intended to evict R1 due to needing a higher level of care. The facility should have also updated R1’s care plan to include R1 was reappraised and required 1:1 care due to falls. LPM and LPA explained regulations requiring proper 2-day written notice of increased care needs and eviction procedures to GPD on 4/20/2022. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the allegation. Therefore, the allegation is Unsubstantiated at this time. The facility will be cited on a case management report for failure to update R1’s care plan appropriately. An Advisory Note for Technical Assistance was issued to counsel the administrator that verbal evictions are not considered proper evictions per Title 22, and an Advisory Note for Technical Assistance was issued to counsel the administrator on proper 2-day written rate increases.
On the allegation: Facility did not allow Resident(s) to have visitors. RP1 stated R1 moved into the facility on 11/21/2019. RP1 stated the staff told RP1 not to visit R1 for two months during R1’s settling in process. RP1 stated staff told them a transition period was “essential” and RP1 would not be able to see R1 for a period of time until facility staff “felt sure” R1 had “adjusted.” RP1 stated they felt like they “could not enter the facility.” As a result, RP1 stated RP1 did not visit R1 over Thanksgiving and Christmas. RP2 stated staff discouraged them from visiting and they were told not to come visit after R2 moved in, to let R2 adjust. According to RP2, the facility staff recommended the resident “disassociate” from their family to adjust to the new environment. RP2 stated they did not comply with that recommendation and visited anyway to ensure R2 was adjusting to the facility. RP2 stated facility staff “frowned upon this” and told RP2 it was best to let R2 settle in. During the interview on 6/22/2021, the Marketing Director stated transition is sometimes difficult for new residents. The Marketing Director stated they tell new residents their home is undergoing construction and tell the family members it may be beneficial to refrain from visiting the resident during the transition. LPA counseled the
Please continue to 9099A-C, Pg 4.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 5 of 14
Control Number 29-AS-20210614172310
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: 04/21/2022
NARRATIVE
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Marketing Director on the importance of accurately messaging the recommendation that residents may experience a better transition into the facility if visitors refrain from visiting, and explained about residents’ personal rights. On 4/20/2022, the Marketing Director stated visitors have never been denied entry into the facility. The Marketing Director stated she recognized the need to change the messaging about the recommendation, and now emphasizes resident’s personal rights during the discussion. In an interview on 4/20/2022, Generations Program Director (GPD) confirmed they alert families/responsible parties as to how the residents are transitioning after moving into the facility. GPD stated if they observe a resident to be agitated after a visit or phone call, they will alert the family/responsible party. GPD confirmed they have never turned away a visitor, and made great efforts to allow for safe visitation during the COVID-19 pandemic. Multiple responsible parties interpreted the facility’s messaging as they could not visit the residents during the transition phase. However, the facility allowed visitation for responsible parties that refused to comply with the policy. An Advisory Note for Technical Assistance was issued to emphasize the importance of accurately messaging the visitation policy to responsible parties and all other visitors. Based on the evidence obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of report emailed. Advisory Notes issued and emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 4 of 14
Control Number 29-AS-20210614172310
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: 04/21/2022
NARRATIVE
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Facility staff did not contact R1’s physician about the change in condition and did not obtain the medication that was ordered. Instead RP1 contacted R1’s physician about the change in condition and obtained the ordered medication. R1 requiring 1:1 care for falls did not absolve the facility of their responsibility to provide care and supervision to R1, including observation of the resident for changes in condition and ensuring R1 received timely medical attention for the suspected UTI. Therefore, based on the evidence obtained, the allegation is deemed substantiated at this time.
On the allegation: Facility did not keep resident's room clean. RP1 stated R1’s floor was dirty under the bed, the room smelled of urine, and candy wrappers were observed on the floor under and behind furniture. LPA observed photos provided by RP1 and observed seven pieces of paper or tissue wadded up on the ground, between a nightstand and the wall, next to the bed. LPA also observed another photo showing shoes on the ground along with two tissues. S4 stated R1’s clothes and shoes were often not where they were supposed to be. Responsible Party 2 (RP2) stated Resident 2 (R2)’s room smelled of urine, and the bathroom floor was dirty and sticky from urine. RP2 stated RP2 cleaned R2’s room on a few occasions due to the condition. S4 stated residents’ 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. On 4/19/2022, LPA toured the facility with Generations Program Director. At 2:14 pm, LPA observed room 219 had a strong odor of urine. At 2:22 pm GPD requested housekeeping to attend to the urine in the room. Based on the information obtained, the allegation is deemed Substantiated at this time.
On the allegation: Facility did not provide resident necessary toiletries. RP2 stated on at least three different occasions, they had to ask staff for toilet paper for R2’s room because there was none. RP1 stated they observed R1’s bathroom was lacking toilet paper on 1/1/2020. On 4/19/2022, LPA toured the facility and observed no toilet paper on the toilet paper holder, nor anywhere else in the bathroom shared by rooms 210 and 211. LPA photographed the empty toilet paper holder. LPA observed toilet paper on the counter of room 210 and observed no toilet paper on the counter of room 211. The counter where toilet paper was observed in room 210 was not within reach of the toilet and is separated by a door. Based on the information obtained, the allegation is deemed Substantiated at this time.

Exit interview conducted. Copy of report emailed. Deficiencies cited on 9099-D. Civil penalty issued. Appeal rights issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 14 of 14