Garden Court At Villa Santa Barbara

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not properly assist with the self-administration of medications. Staff do not refill residents’ medication prescription in a timely manner.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced subsequent complaint visit to deliver final findings for the above-stated allegations. During today’s visit, LPA met with Administrator Robert Glock and explained the purpose of the visit. LPA Kontilis conducted the initial visit on 3/11/2025 from approximately 11 am – 6:15 pm at which time LPA conducted interviews and obtained documents pertaining to the investigation. On the allegation, Staff did not properly assist with the self-administration of medications: It has been alleged that Medication Technicians (Med Techs) administered incorrect medication(s) to residents and substituted medications when a resident’s medications were not available. Additionally, reporting party stated when Resident 1 (R1) had voiced to fellow residents that R1 had to correct Med Techs so as R1 would not be administered incorrect medications, the other residents voiced similar experiences with their medications. Record review revealthe state’s words, verbatim · CDSS document, May 5, 2026 · control 29-AS-20260309111520

Allegation investigated: Staff is stealing medication from a resident in care.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Robert “Bob” Glock and explained the purpose of the visit. LPA De Leon conducted the initial 10-day visit on 03/24/2026, requested records, conducted interviews with Administrator at 2:40pm, Staff at 5:45pm and audited the Medication cart for R1’s medications. LPA De Leon interviewed additional staff on 04/03/2026 at 4:08pm and 5:29pm, on 04/06/26 at 2:43pm, on 04/29/26 at 3:10pm and on 04/30/26 at 1:50pm, 2:29pm, and 2:41pm. On the allegation: Staff is stealing medication from a resident in care. Based on observation from LPA De Leon auditing the Medication cart for Resident 1’s (R1’s) medications, R1’s cycle medication was audited first. The bubble packs appeared to have the correct count of medication used for March 23, 2026. Continued 9099-C Substantiatedthe state’s words, verbatim · CDSS document, May 5, 2026 · control 29-AS-20260323223249

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not provide proper accommodations to residents in care.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a 10-day initial visit to the above-named facility. LPA met with Administrator Robert Glock and explained the purpose of the visit. On the allegation Staff did not provide proper accommodations to residents in care: Reporting Party provided information stating the allegation is based on written notification distributed to residents stating ‘water in the facility will be shut off between 10:00 pm and 5:00 am on Monday through Saturday Nights, March 9-14…’ During today’s visit, LPA obtained notification titled, “From the desk of Executive Director…March 7, 2026…” The notification verifies that residents in care have been informed that "plumbing work will occur between 10:00 pm and 5:00 am on Monday through Saturday Nights, March 9-14. During this time, the water will be shut off in the building, and you will be unable to flush your toilets because the drainage pipes being replaced are sewage and wastewater pipes…” Interview conduthe state’s words, verbatim · CDSS document, Mar 10, 2026 · control 29-AS-20260309155422

Allegation investigated: Licensee does not ensure that the facility is maintained in a sanitary condition.

On February 18, 2026 at 11:00am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to investigate the allegation to this complaint. LPA met with Backup Administrator Apple Pelare and explained the purpose of the visit. During the visit, LPA interviewed staff, residents, the Backup Administrator, Wellness Director TIna Tran, and obtained relevant documents. On allegations, licensee does not ensure that the facility is maintained in a sanitary condition. The Department recieved photos of what appears to be a metal tray with two small round mounds of what is alleged to be mold and what appears to be a yellow leaf. (Continued on LIC 9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 18, 2026 · control 29-AS-20260212121521

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff engages in inappropriate behavior with another staff in the presence of residents. Staff does not provide a healthy and safety environment to residents. Staff withhold food from residents. Staff does not accommodate resident's food needs. Staff does not allow resident visitors.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent visit to the facility to issue final findings. LPA met with Administrator Robert Glock and explained the purpose of the visit. During the investigation, LPA requested relevant documents and conducted interviews with staff on 12/20/2024 from 10:40 am to 12:30 pm. On 12/5/2025, LPA conducted a subsequent visit to the facility and conducted interviews with residents and staff from 11:20 am to 3:40 pm and obtained documents pertaining to the investigation. On 12/9/2025, LPA conducted additional telephone interviews with staff and residents from 12:00 pm to 3:10 pm and 12/10/2025, from 8:03 am to 230 pm. On the allegation: Staff engages in inappropriate behavior with another staff in the presence of residents. It was alleged two staff were in a relationship and were inappropriate, “fraternizing,” and embracing. Administrator stated staff typically create friendships but was unaware of two staff in a relationship and stathe state’s words, verbatim · CDSS document, Dec 10, 2025 · control 29-AS-20241218153653

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not answer resident's call button in a timely manner, resulting in resident sustaining a fracture.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Administrator Robert Glock and explained the purpose of the visit. On 10/01/2024, the Department received a complaint report for alleged neglect/lack of care and supervision by facility staff that resulted in a fracture. The complaint alleged that the facility failed to respond to and seek medical attention in a timely manner for Resident 1 (R1). The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Johnny Canto. On 10/02/2024, from 9:45 am to 11:15 am, Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced initial complaint investigation visit based on the above allegation. LPA Kontilis met with Robert Glock, Administrator, and explained the purpose of the visit. Tina Tran, Wellness Director, joined during the visit. During the visit, the LPA obtthe state’s words, verbatim · CDSS document, Apr 14, 2025 · control 29-AS-20241001130402

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: 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.

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. Athe state’s words, verbatim · CDSS document, Sep 6, 2024 · control 29-AS-20230918112215

Allegation investigated: Facility staff did not meet resident's needs.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Robert Glock, Administrator, and Tina Tran, Wellness Director and explained the purpose of the visit. During the investigation, LPA Kontilis conducted an initial visit on 5/22/2024 from 10:14 am to 3:45 pm, toured the facility, obtained documents, and interviewed staff. On the allegation: Facility staff did not meet resident's needs. It was reported Resident 1 (R1) sustained pressure injuries at the facility. The investigation revealed on 4/18/2024, R1 moved into the facility from a Skilled Nursing Facility. On 4/26/2024, R1 fell and went to the hospital. At the hospital, it was discovered R1 had “sores” on their back side and groin that were believed to be consistent with sitting in a soiled brief too log. A witness interviewed confirmed R1 was at the facility for only about one week before they went to the hospital. On 5/8/2024, R1 returnthe state’s words, verbatim · CDSS document, May 29, 2024 · control 29-AS-20240514113058

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are refusing to allow resident to remove their personal belongings from the facility.

Licensing Program Analysts (LPA's) Olson and Miller conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA obtained documents and interviewed staff on 10/11/23 at 1:30pm and 2pm. LPAs met with Business Director and explained the purpose of the visit. On the allegation: Staff are refusing to allow resident to remove their personal belongings from the facility. It was alleged on 10/2/23 Administrator refused to allow the moving company to pick up R1’s equipment and demanded to speak with the patient before releasing the equipment. LPA interviewed Administrator and Wellness Director who stated they met with R1 on 9/27/23 and 9/29/23 relaying their wishes to return to the facility. Administrator stated they had new equipment ordered such as a hospital bed and Hoyer lift to help R1 come home. On 9/29/23 R1 stated they were ready to come home. On 9/30/23 Administrator went to the SNF to pick up the resident but was denied access and told thethe state’s words, verbatim · CDSS document, Dec 11, 2023 · control 29-AS-20231004170559

Allegation investigated: Staff do not answer resident’s call button in a timely manner.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to the facility. LPA met with Administrator Mark Cortes and explained the purpose of the visit. On the allegation, Staff do not answer resident’s call button in a timely manner: It was alleged that staff does not respond when R1’s care pendant has been pressed and R1 has had to wait 30-45 minutes before staff responds to the calls. R1 is non-ambulatory and requires assistance with toileting and brief changes. R1’s call pendant history revealed between 9/13/2023 and 9/17/2023, there were eight (8) occurrences when R1’s call pendant was pressed. Out of the eight call pendant requests, four calls were made between 6:00 am and 12:00 pm and two calls were made between 6:00 pm and 12:00 am. The eight call requests were responded to within 10-29 minutes. Staff 1 (S1) stated sometimes the call response button does not clear the resident’s pendant. Administrator stated that on occasion, a caregiver respondsthe state’s words, verbatim · CDSS document, Sep 20, 2023 · control 29-AS-20230918112215