425802118-1-12-2024-29-AS-KBUY-D9FUHD-20240925153545

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802118
Report Date: 01/12/2024
Date Signed: 01/12/2024 04:26:36 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
01/08/2024 and conducted by Evaluator Kristin Kontilis

COMPLAINT CONTROL NUMBER: 29-AS-20240108210433

FACILITY NAME:	OAK COTTAGE OF SANTA BARBARA MEMORY CARE		FACILITY NUMBER:	425802118
ADMINISTRATOR:	ANDREA KATZ		FACILITY TYPE:	740
ADDRESS:	1820 DE LA VINA STREET		TELEPHONE:	(805) 456-7270
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY:	50	CENSUS: 35	DATE:	01/12/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Jovany Guerra, Senior Resident Care Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not provide adequate supervision to a resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kristin Kontilis conducted an initial 10-Day complaint visit on the above-stated allegation. LPA met with Jovany Guerra, Senior Resident Care Director (SRCD) and announced the purpose of the visit. At the time of arrival Administrator Andrea Katz was not available.
During today’s visit, from 12:00 pm to 4:00 pm, LPA conducted interviews and obtained documents pertinent to the investigation.
On the allegation, Staff did not provide adequate care and supervision to a resident: It was alleged that lack of supervision resulted in R1 eloping from the facility on 2/10/2023. Information gathered reflected that R1 has a diagnosis of Dementia and was admitted into the facility on 9/22/2021. Interviews conducted and records reviewed revealed that R1 eloped from the facility at approximately 1:01 am on 2/10/2023. Interviews further reflected that 9-1-1 was called by facility staff to alert emergency responders to assist in a perimeter search for R1. Jovany Guerra, Resident Care Director stated R1 was found by a represnetative from the

Please continue to 9099-C, Pg 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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-20240108210433

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: 01/12/2024

NARRATIVE

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This is an amended report. Santa Barbara Police Department (SBPD). Guerra stated he was unsure whether it was an officer from SBPD but was certain it was a representative from SBPD. Guerra further stated R1 was taken to the local hospital for evaluation. Record review revealed the hospital evaluation determined R1 sustained a skin tear and brain bleed as a result of the hospital evaluation. Medical records specify R1 sustained bilateral subdural hematomas. Guerra stated R1 did not return to the facility after R1's elopement. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that due to lack of supervision R1 eloped from the facility; therefore, the above allegation is deemed SUBSTANTIATED at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the CA Code of Regulations, Title 22 Regulations. A civil penalty of $500 is assessed due to R1 sustaining an injury as a result of a deficiency.

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

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240108210433

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: 01/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/13/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities. 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 is not met as evidence by:	1 2 3 4 5 6 7	SRCD agrees to conduct an in-service with all staff covering elopement policies, procedures, and drills. SRCD will notify LPA via email no later than 5:00 pm on 1/14/2024 as to the date the in-service will be held. SRCD agrees to conduct all-staff in-service by 5:00 pm on 1/19/2024.
	8 9 10 11 12 13 14	Based on interviews and records reviewed Licensee did not ensure supervision was provided to R1; as a result R1 eloped from facility.	8 9 10 11 12 13 14	SRCD agrees to provide first & last names and signatures of attendees, description of in-service, and date(s) in-service was held.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
01/08/2024 and conducted by Evaluator Kristin Kontilis

COMPLAINT CONTROL NUMBER: 29-AS-20240108210433

FACILITY NAME:	OAK COTTAGE OF SANTA BARBARA MEMORY CARE		FACILITY NUMBER:	425802118
ADMINISTRATOR:	ANDREA KATZ		FACILITY TYPE:	740
ADDRESS:	1820 DE LA VINA STREET		TELEPHONE:	(805) 456-7270
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY:	50	CENSUS: 35	DATE:	01/12/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Jovany Guerra, Senior Resident Care Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not address a resident's change in medical condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kristin Kontilis conducted an initial 10 Day complaint visit on the above-stated allegation. LPA met with Jovany Guerra, Senior Resident Care Director (SRCD) and announced the purpose of the visit. At the time of arrival Administrator Andrea Katz was not available.
During today’s visit, from 12:00 pm to 4:00 pm, LPA conducted interviews and obtained documents pertinent to the investigation.
On the allegation, Staff did not address a resident’s change of condition: Resident 1 (R1) was admitted into the facility on 9/23/2021. Documents revealed from 11/18/2022 to 2/10/2023, staff discovered R1 on the floor in R1’s bedroom and/or bathroom on 11/18/2022, 12/6/2022, 12/20/2022, 1/27/2023, and 2/9/2023; on 2/1/2023 R1 was transported to the hospital due to looking pale, had generalized weakness, was cold at the touch, and was vomiting; on 2/10/2023, staff discovered R1 had eloped from the facility.

Please continue to 9099-C, Pg 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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 5

Control Number 29-AS-20240108210433

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: 01/12/2024

NARRATIVE

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This is an amended report. During today’s visit, SRCD stated a Service Plan Meeting was scheduled on 9/16/2021 upon R1’s admission into the facility. Record review indicated R1’s Service Plan was updated on 9/29/2022 and 12/22/2022. SRCD further stated a Service Plan Meeting was scheduled to be held with R1’s responsible party on 2/14/2023. SRCD stated the Service Plan Meeting scheduled to be held on 2/14/2023 was to address changes of condition, emergency contact information, medication records, resident’s weight and current status, resident’s level of care and fall risk, interventions, latest Physician’s Report, Service Plan, and an open discussion regarding service and care. The Service Plan Meeting would include any/all hospitalizations, incidents, and elopements. SRCD stated he scheduled the Service Plan Meeting on or about 2/7/2023 and notified R1’s responsible party of the meeting prior to 2/7/2023. Based on interviews conducted and records reviewed, LPA determined that the facility updated R1’s service plan after residing in the facility for a year, and then following the third found on floor incident. Additionally, although the Service Plan Meeting on 2/14/2023 did not come to fruition due to R1 moving out of the facility, SRCD Guerra addressed the resident’s change of condition following one additional found of floor incident by scheduling the Service Plan Meeting with R1’s responsible party. Therefore, the allegation that staff did not address a resident’s change of condition is deemed Unsubstantiated at this time.

Exit interview conducted. Report issued at the time of the visit.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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