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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802118
Report Date: 12/20/2023
Date Signed: 12/20/2023 04:27:49 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
10/13/2021 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20211013143424
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: 37DATE:
12/20/2023
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jovany Guerra, Senior Resident Care DirectorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not meet resident's diapering needs
Staff did not adequately manage resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kontilis conducted a subsequent complaint visit to issue final findings for the complaint allegations above. LPA met with Jovany Guerra, Senior Resident Care Director and explained the purpose of the visit. During the investigation, LPA reviewed relevant documents, and conducted interviews with responsible parties on 9/16/2021 and 10/4/2021, and staff on 12/18/2023.

On the allegation: Staff did not meet resident's diapering needs. It was alleged that R1 was wearing two briefs, with the first brief soiled. R1’s responsible party confirmed on one occasion, they observed R1 wearing two briefs. Staff interviewed stated they were aware of other staff double diapering residents in the past. Facility nurse confirmed double diapering is against the facility’s policy, and around the time of this complaint they became aware that a caregiver double diapered residents at the facility. Facility nurse stated they held an in-service training with all staff to address the issue, and confirmed it is no longer happening. Based on the information obtained, the allegation is deemed Substantiated at this time.
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: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
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 6
Control Number 29-AS-20211013143424
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: 12/20/2023
NARRATIVE
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On the allegation: Staff did not adequately manage resident's medication. It was alleged that from 6/29/2021 through 7/3/2021, R1 was given PRN medication but staff gave the PRN pre-emptively in anticipation of a behavioral issue (not per physician’s orders). Staff interviewed stated PRNs should not be given pre-emptively and staff should wait until the symptoms/behaviors specified on the PRN order are observed. Facility nurse confirmed they became aware on 7/6/2021 that a med tech gave PRNs inappropriately and on 7/7/2021 they counselled the med tech on the policy on PRNs. Facility nurse confirmed they did not have the problem reoccur after the counselling. 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 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

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

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20211013143424
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: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2023
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidenced by:
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Facility nurse counselled staff about the medication issue on 7/7/2021. POC cleared.
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Based on interviews, the licensee did not comply with the above cited section when they did not follow physician’s orders for R1’s PRN, which posed an immediate health and safety risk to residents in care.
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Type B
12/22/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional 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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Sr RCD agrees to one of the following:
Provide written verification of 2021 in-service for facility's care policy encompassing toileting, brief changing, and personal rights OR will conduct an in-service with all care staff covering the facility's care policy encompassing toileting, brief changing, and personal rights.
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Based on interviews, the licensee did not comply with the above cited section when they double diapered residents, which posed a potential health and safety risk to residents in care.
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Proof of training includes first & last names of attendees, dates, description & trainer's first & last name.
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: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
10/13/2021 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20211013143424

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: 37DATE:
12/20/2023
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jovany Guerra, Senior Resident Care DirectorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not prevent inappropriate behavior between residents.
Staff did not encourage resident's involvement in group activities while their one-one caregiver was present.
Facility did not notify of Resident's change of condition.
Facility staff denied Resident visitation.
Facility abandoned Resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kontilis conducted a subsequent complaint visit to issue final findings for the complaint allegations above. LPA met with Jovany Guerra, Senior Resident Care Director and explained the purpose of the visit. During the investigation, LPA reviewed relevant documents, and conducted interviews with responsible parties on 9/16/2021 and 10/4/2021, and staff on 12/18/2023.
On the allegation: Staff did not prevent inappropriate behavior between residents. It was alleged that Resident 1 (R1) entered another resident’s room and pushed the resident, causing them to fall. R1’s responsible party admitted during interview that they found R1 to have short incidents of 5-10 minutes where they would be aggressive and combative and the behavior could come on suddenly, and they resolved quickly as well. R1’s responsible party stated on one occasion, the facility called 9-1-1 but the paramedics did not want to take R1 to the hospital, since they did not meet emergency room criteria. R1’s responsible party stated they interpreted from this that R1’s incidents are very spontaneous, and R1 reverts quickly back to their usual self, compoed and docile. R1’s responsible party confirmed these incidents all happened
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: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20211013143424
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: 12/20/2023
NARRATIVE
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in the first two weeks that R1 moved into the facility. R1’s responsible party also stated that R1 had “outbursts” and “you never knew they were going to happen, they just seem to happen.” Administrator recommended a psychiatric hospital for R1 due to their unusual and sporadic behaviors, or a one-on-one staff. Facility nurse stated they tried many different interventions with R1 including contacting R1’s physician and holding care conferences to discuss changing needs. R1 had a one-on-one staff after the need was identified. Based on the information obtained, R1’s behaviors were not due to a lack of supervision, and additional supervision was provided once the need was identified. Therefore the allegation is deemed Unsubstantiated at this time.
On the allegation: Staff did not encourage resident's involvement in group activities while their one-on-one caregiver was present. It was alleged that when R1’s one-on-one private caregiver was present, staff would not involve R1 in group activities. Interview with R1’s visitor revealed that it appeared R1 got less attention from facility staff due to having a one-on-one caregiver present. Staff interviews revealed that all residents are encouraged to participate in activities, regardless of whether they have a one-on-one caregiver. Staff stated sometimes if residents are having behaviors or being disruptive, staff will redirect them and engage them one-on-one until the behaviors suppress. Staff stated even if they do not have a private one-of-one, sometimes an activity person works with them one-on-one. Staff stated they have an activities calendar posted and caregivers are assigned certain residents, which includes going to their rooms and encouraging them to participate in activities. Staff stated they do not encourage residents to be isolated in their rooms and encourage residents to participate every day. During visits to the facility, LPA observed residents participating in activities. Due to insufficient evidence to prove the allegation, the allegation is deemed Unsubstantiated at this time.
On the allegation: Facility did not notify of Resident's change of condition. It was alleged that the facility notified R1’s doctor of incidents but did not notify R1’s responsible party. R1’s responsible party indicated the facility contacted R1’s physician to see if additional medications were appropriate, without first notifying the responsible party of the incident. R1’s responsible party learned of the incident from the physician contacting them. LPA reviewed incident reports for R1 dated 6/13/2021 and 6/17/2021, which both indicated R1’s responsible party was notified as well as physician and a care conference and medical evaluation would be scheduled. Both the responsible party and physician were contacted timely; therefore the allegation is deemed Unsubstantiated at this time.

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: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20211013143424
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: 12/20/2023
NARRATIVE
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On the allegation: Facility staff denied Resident visitation. It was alleged that staff encouraged R1’s visitors to not visit after R1 moved into the facility. Reporting party admitted this was a recommendation by staff in order to try to help R1 adjust to the facility. Visitor stated they followed facility’s recommendation. After R1 had a confrontation with another resident, the visitor was told to disregard the recommendation to not see R1 during the transition to make it easier. During an interview on 6/22/2021 with the Marketing Director, she 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 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 have made great efforts to allow for safe visitation during the COVID-19 pandemic. Based on the information obtained, the allegation is Unsubstantiated at this time. Technical Assistance was issued to the facility on 4/21/2022.
On the allegation: Facility abandoned Resident. It was alleged that when R1 was in the hospital, the facility would not accept R1 back into the facility. Around the end of June 2021, R1’s responsible party received a phone call from corporate warning them that a 30-day eviction notice might be issued due to R1’s behaviors and increased level of care. On one occasion where R1 went to the hospital, and R1’s responsible party was told by hospital personnel R1 was not being allowed to return to the facility. As a result, R1 allegedly needed additional sedation to perform a COVID-19 test for another facility they might be transferred to. R1 was hospitalized for multiple days, and the facility stated they would accept R1 back to the facility once R1 was ready for discharge. R1’s responsible party confirmed an eviction notice was never issued. The facility did not refuse to accept R1 back once they were ready for discharge; therefore the allegation is Unsubstantiated at this time. LPA counselled Administrator about proper eviction notices and procedures.

Exit interview conducted. Copy of report 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: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6