425850241-9-6-2024-29-AS-KBUY-D9LVGP-20240930162551

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850241
Report Date: 09/06/2024
Date Signed: 09/06/2024 05:28:28 PM

Unsubstantiated

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
09/18/2023 and conducted by Evaluator Kristin Kontilis

COMPLAINT CONTROL NUMBER: 29-AS-20230918112215

FACILITY NAME:	GARDEN COURT AT VILLA SANTA BARBARA		FACILITY NUMBER:	425850241
ADMINISTRATOR:	RICK OLDS		FACILITY TYPE:	740
ADDRESS:	227 E. ANAPAMU STREET		TELEPHONE:	(805) 963-4428
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY:	126	CENSUS: 96	DATE:	09/06/2024
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Robert Glock, Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff do not assist resident with incontinence needs.
Staff do not keep the facility free of odor.
Resident developed a pressure injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA met with Robert Glock, Administrator and Tina Tran, Wellness Director and explained the reason for the visit. The initial visit was conducted on 9/19/2023 from 12:40 pm to 3:45 pm by LPA Kontilis. LPA conducted interviews and obtained relevant documents. LPA conducted a subsequent visit on 9/20/2023 from 2:45 pm to 5:00 pm. LPA toured the facility, interviewed residents and staff, and obtained additional documents. LPA also conducted additional interviews of visitors and hospice personnel by phone.
On the allegation: Staff do not assist resident with incontinence needs. It was alleged Resident 1 (R1) was frequently found in soiled, wet briefs due to staff not assisting appropriately. One visitor interviewed stated they believe staff tried to care for the residents, but they did not have enough staff to meet their needs. A witness interviewed stated sometimes they had found R1 wet, and if so they would change them.

Please continue to 809-C, Pg 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
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.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230918112215

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: GARDEN COURT AT VILLA SANTA BARBARA	FACILITY NUMBER: 425850241
	VISIT DATE: 09/06/2024

NARRATIVE

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This is an amended report.
Witness stated they could not provide any indication the facility was not changing R1. R1’s private caregiver stated that staff have sometimes asked them to help rotate R1 to avoid pressure injuries, but did not ask the private caregiver to help with incontinence care. Private caregiver also stated they did not notice any odors. Residents interviewed indicated staff were slow to respond to call buttons, and Former Wellness Director admitted the facility was working on this issue. However, no residents indicated their needs were not met. Based on the information obtained, there was insufficient evidence to prove the allegation occurred. Therefore, the allegation is deemed Unsubstantiated at this time.
On the allegation: Staff do not keep the facility free of odor. It was alleged the facility smelled like urine.
Two visitors interviewed stated they had not observed any odors. During LPA visits on 9/19/2023, 9/20/2023, 10/11/2023, 12/11/2023, 2/27/2024, 3/6/2024, 5/22/2024, 5/29/2024, and 9/6/2024, LPA did not observe any bad odors. All residents interviewed did not indicate any foul odors in their rooms or the common areas. One resident stated they noticed an odor in the hallway at times, but believed it was what staff were using to clean the carpets. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.
On the allegation: Resident developed a pressure injury while in care. It was alleged R1 sustained a “wound” due to their briefs not being changed. It was noted that due to using a barrier cream and specialized mattress, the “sore” had gotten better. Upon interview with R1’s responsible party, they stated hospice did not refer to it as a bed sore (pressure injury), but it was a “wet mark” caused by irritation that becomes a rash. Hospice applied a salve and said it was “taken care of.” LPA interviewed R1’s hospice nurse, who confirmed it was not a pressure injury, it was moisture-associated skin damage. Hospice nurse stated it was very common due to moisture trapped inside a brief, and the moisture breaks the skin down. Hospice nurse indicated the skin damage was in the buttocks area between the cheeks, where moisture can get trapped as it is an area difficult to dry. Hospice nurse stated it has since healed. Former Wellness Director confirmed the facility noticed the red rash on R1 first and reported it to hospice. Former Wellness Director also instructed staff to increase checks on R1, as R1 was relying more on briefs than using the toilet or commode as their mobility decreased. Former Wellness Director stated she takes skin care very seriously. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview, copy of report issued at the time of the visit.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

LIC9099 (FAS) - (06/04)

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