425850241-2-27-2024-29-AS-KKOS-D2V2W8-20240227164509

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850241
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:46:57 PM

Document Has Been Signed on 02/27/2024 04:46 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:	GARDEN COURT AT VILLA SANTA BARBARA		FACILITY NUMBER:	425850241
ADMINISTRATOR:	KAROLYN SORENSON		FACILITY TYPE:	740
ADDRESS:	227 E. ANAPAMU STREET		TELEPHONE:	(805) 963-4428
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY:	126	CENSUS: 88	DATE:	02/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:53 AM
MET WITH:	Robert Glock		TIME COMPLETED:	05:00 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 Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection to the above-named facility. The facility is licensed as a Residential Care Facility for the Elderly (RCFE). Upon arrival, LPA met with Executive Director Robert Glock and announced the purpose of the visit. Administrator Karolyn Sorenson was not available at the time of the visit. The facility is licensed for 126 non-ambulatory residents and a hospice waiver for 10 residents. Currently, there are 88 residents residing in the facility.There is one resident currently on hospice. Entrance Interview Conducted: The facility is four stories with no bodies of water. Entrance into the facility is the Ground floor which leads into a large common area, reception area, administrative offices, and a large dining area. There is an outdoor patio off the dining area conducive for social distancing. Also on the ground floor are an activity room, activity offices, hair salon, laundry rooms, a library, and the kitchen. The kitchen is a large industrial size kitchen consisting of grills, ovens, heating lamps, fryers, industrial size refrigerators and freezers, large pantries for food storage, and a dishwashing station. Floor #1 consists of Nurses’ station, Nurse’s office, testing room, approximately 74 residents’ rooms, Physical Therapy/Gym room, an outdoor patio, and a staff break room. Residents’ records are kept in the Nurses’ station on Floor #1. Floor #2 is residents’ rooms only. Floor #3 consists of a rooftop deck with open-air outdoor seating and covered outdoor seating, potted plants, and panoramic views. Residents may participate at will in various activities based on their individual interests and preferences. Activities include mental wellness sessions, historical biographical mapping, book club, garden club, residents' social gatherings, religious study groups, singing groups, chair yoga, eye-hand coordination activity, Bingo, aroma therapy, celebrations of special events and holidays, scenic excursions to local interest sites and excursions to local retail businesses and eateries. Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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: GARDEN COURT AT VILLA SANTA BARBARA	FACILITY NUMBER: 425850241
	VISIT DATE: 02/27/2024

NARRATIVE

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During today’s visit, the medication inventory and Medication Administration Record (MAR) for Resident 1 (R1) revealed an overcount of Aspirin Low Dosage 81mg began on 2/16/2024 with a bottle count of 30. R1’s prescribed medication is 1x per day in the AM administered on 2/16/2024 through 2/27/2024. At approximately 1:52 pm, Staff 1 (S1) counted an overcount of 21 tablets in the bottle.
R1’s prescribed medication of Levothyroxine 75 mcg with a bottle count of 30 started on 12/30/2023 MAR revealed R1 did not take one dose on 1/21/2024. At approximately 2:00 pm, S1 counted an overcount of 34 tablets in the bottle. At approximately 2:05 pm, S1 and Executive Director Glock re-counted the Levothyroxine medication and determined there was an overcount of 34 tablets in the bottle.
R1 has a Doctor’s order for Memantine 10mg, (60 count) 1 tablet twice per day in the AM and Bedtime. The medication was started on 12/30/2023. At approximately 2:24 pm, S1 counted 46 tablets remaining in the bottle. R1's MAR revealed the medication was administered to R1 from 12/30/2023 through 2/27/2024.
During today’s visit, the medication inventory for R1 revealed approximately eight (8) expired medications. At approximately 3:30 pm, Staff 2 (S2) completed LIC622 Centrally Stored Medication and Destruction Record. Executive Director Glock stated the expired medications will be properly destroyed by 2/29/2024.

Due to time restraints, LPA will return at a later date to continue the annual inspection.

The following deficiencies were observed (see LIC 809-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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/27/2024 04:46 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: GARDEN COURT AT VILLA SANTA BARBARA	FACILITY NUMBER: 425850241
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Type A: 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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews conducted, and record review, the licensee did not comply with the section cited above when it was determined that there was an unexplainable overcount of R1's medications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	Licensee agrees to provide a written plan in place as to the completion of a "MAR to Cart" medication audit to ensure accurate pill count, prescription expiration, and Physician's orders. Written plan in place will be submitted via email no later than 4:00 pm on 2/29/2024.

Type A

Section Cited

CCR

87465(i)

87465(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: (1) Name of the resident. (2) The prescription number and the name of the pharmacy. (3) The drug name, strength and quantity destroyed. (4) The date of destruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews conducted, and record review, the licensee did not comply with the section cited above as there were 8 bottles of expired medications located in the care center belonging to R1 which poses an immediate health and safety risk to residents in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	Executive Director agrees to properly destroy medications per CCR87465(i). Executive Director agrees to submit written statement acknowledging destruction of medications via email.

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: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

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