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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802118
Report Date: 09/06/2024
Date Signed: 09/09/2024 08:01:15 AM


Document Has Been Signed on 09/09/2024 08:01 AM - 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:TYLER BARNESFACILITY TYPE:
740
ADDRESS:1820 DE LA VINA STREETTELEPHONE:
(805) 456-7270
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:50CENSUS: 35DATE:
09/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Tyler Barnes, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management visit to issue deficiencies discovered after reviewing incident reports. LPA met with Tyler Barnes, Administrator and explained the purpose of the visit. During the investigation, LPA Kontilis reviewed relevant documents and interviewed staff.
LPA reviewed an incident report (IR) received 07/17/2024 that stated on 07/15/2024, Staff 1 (S1) failed to provide Resident 1 (R1) Morphine SO4 15mg tablet. R1’s physician was contacted on 07/17/2024 and R1 was placed on alert charting for 48 hours. The IR states med techs were provided medication training as a result of the medication error.
An IR received on 07/19/2024 states on 06/30/2024, Staff 2 (S2) failed to provide medication to eleven residents in care. LPA requested physician’s orders for medications, Medication Administration Records (MARs) and staff schedules for June and July 2024. On 07/23/2024, LPA received a revised IR which provided additional information.
The following medication errors were noted for 06/30/2024:
-R2 did not receive their 8:00 pm: Senna 8.6 mg and Melatonin 5mg
-R3 did not receive their 8:00 pm: Donepezil HCL 10mg and Mirtazapine 7.5mg
-R4 did not receive their 5:00 pm: Biotrue Hydration Boost Eye Drops, Senna 8.6mg, Cephalexin 500mg
-R5 did not receive their 8:00 pm: Ketorolac Tromethamine 0.5% Eye Drops, Timolol Maleate 0.5% Eye Drops, Quetiapine 25mg, Venlafaxine HCL ER 75mg
-R6 did not receive 8:00 pm: Donepezil 10mg; Atorvastatin Calcium 20mg
-R7 did not receive their 5:00 pm: Calcium 600-VitD3 600mg; 8:00 pm: Montelukast Sodium 10mg; Sertraline HCL 100mg; Donepezil HCL 5mg
-R8 did not receive their 8:00 pm: Lorazepam 0.5mg, Quetiapine 25mg, Polyethylene Glycol 17mg
-R9 did not receive their 5:00 pm: Memantine HCL 10mg, Acetaminophen 325mg, Preservision AREDS 250-90-40, Vitamin C 1,000mg; 8:00 pm: Donepezil 10mg, Melatonin 5mg

Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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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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: 09/06/2024
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-R10 did not receive their 5:00 pm: Aspirin 81mg, Atorvastatin Calcium 40mg
-R11 did not receive their 5:00 pm: Flecainide Acetate 100mg, Atorvastatin Calcium 20mg, Triamcinolone Acetonide 0.1% cream
-R12 did not receive their 5:00 pm: Hydrocodone 5mg, Famotidine 20mg; 5:30 pm: Senna 8.6mg; 8:00 pm: Trazadone HCL 50mg

The incident reports indicate resident’s physicians were contacted on 07/17/2024, after the discrepancies were discovered. Additionally, all affected residents were placed on alert charting for 48 hours after the discovery.
The IR states S2 was terminated from the facility, and other med techs were to receive ongoing training to review policies and procedures for medications. LPA discussed the importance of accurate assistance with medication with the new Administrator.
Additionally, on 08/28/2024, 08/29/2024, and 9/5/2024, LPA reviewed three incident reports for R13 that indicated R13 had multiple private caregivers. The private caregivers had fingerprint clearance but were not associated to the facility.
Additionally, record review and interviews conducted revealed the facility contracts with an outside home health agency for additional staffing when needed as well as 1:1 for private care. Records reviewed revealed 10 temporary staff members had fingerprint clearance but were not associated to the facility.

The following deficiencies were observed (See LIC 809-D.) and cited from the CA Code of Regulations, Title 22 Regulations. Civil penalty assessed for criminal record clearance transfer violation.

Exit interview conducted. A copy of the report and civil penalties was issued at the time of the visit along with appeal rights.

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

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/09/2024 08:01 AM - 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: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2024
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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S2 was terminated. Administrator agrees to provide proof S1 and other staff were retrained in mediation procedures. Administrator agrees to submit a written plan to ensure residents will receive their medication as prescribed.
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Based on interview and record review, the licensee did not comply with the section cited when multiple residents did not receive their medication as prescribed, which posed an immediate health and safety risk to residents in care.
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Type A
09/09/2024
Section Cited
CCR87355(e)(2)

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87355(e)(2) Criminal Record Clearance. All individuals subject to a criminal record review…shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by:
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Administrator agrees to associate all private caregivers to the facility and provide proof of correction by 9/9/2024.
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Based on interview and record review, the licensee did not comply with the section cited when thirteen private and/or temporary caregivers were not associated, 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: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/09/2024 08:01 AM - 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: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2024
Section Cited
CCR
87211(a)(1)

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87211(a)(1) Reporting Requirements:A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D)...
This requirement is not met as evidenced by:
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Administrator agrees to provide staff training to all staff who are responsible for reporting incidents/illnesses to Administrator. Administrator agrees to provide proof of training via email to include date of training, description, first and last names of trainee, and first and last names of trainers.
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Based on interview and record review, the licensee did not comply with the section cited when a medication error of 12 residents occurred on 6/30/2024 and not reported until 7/19/2024 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: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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