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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850241
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:47:46 PM

Document Has Been Signed on 01/15/2025 02:47 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 BARBARAFACILITY NUMBER:
425850241
ADMINISTRATOR/
DIRECTOR:		ROBERT GLOCKFACILITY TYPE:
740
ADDRESS:227 E. ANAPAMU STREETTELEPHONE:
(805) 963-4428
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY: 126CENSUS: 96DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:59 AM
MET WITH:Robert Glock, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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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 Wellness Director, Tina Tran, RN. LPA announced the purpose of the visit. The facility is licensed for 126 non-ambulatory residents and a hospice waiver for 10 residents. Currently, there are 96 residents residing in the facility and two residents are 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 and outdoot covered 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.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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: 01/15/2025
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During today’s visit, the medication inventory and Medication Administration Record (MAR) for Resident 1 (R1) revealed the following: R1 is prescribed two tablets of Senna 8.6mg by mouth each evening. Medication inventory revealed R1 was administered one tablet each day, not two as prescribed. Prescription states “Hold for loose stools or diarrhea”. MAR reflects R1 refused medication on 1/1/2025. R1 is prescribed 400mg of Acyclovir, 1 tablet by mouth twice daily. Based on the recorded “opened” date, the medication inventory revealed one extra tablet was administered to R1.

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

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2025 02:47 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 01/15/2025 at 02:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
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
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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 under-count of R1's medications which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Administrator agrees to conduct a staff training to include recording start date of medication; refusals; discarded/lost medicaitons; discarding narcotics, attendees w/signatures; and date training(s) will be conducted. Administrator agrees to provide date of training to LPA via email no later than POC due date (1/17/2025).
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
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