Garden Court at Villa Santa Barbara

Allegation investigated: Staff did not assist resident with obtaining care in a timely manner. Staff did not observe resident for a change in condition.

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 5/5/2026 from approximately 11:30 am – 5:15 pm at which time LPA conducted interviews and obtained documents pertaining to the investigation. During today’s visit, Long Term Care Ombudsman Diane See participated in the investigation. On the allegation, Staff did not assist resident with obtaining care in a timely manner: Reporting Party voiced concern that facility staff did not observe Resident 1’s (R1’s) change in condition when R1 developed a Urinary Tract Infection (UTI) and was not provided timely medical attention. Based on interviews conducted and records reviewed, R1 was found on the floor by R1’s visitor who alerted facility staff at which time, facility staff assisted R1 and called 9-1-1 for assistance. R1 was transferred to the local hospital and administered care therein. Interviews conducted revealed R1 stated they did not want to go to the hospital however, Please continue to 9099-C, Pg 2. Unsubstantiated facility staff insisted calling 9-1-1 is the proper protocol to ensure residents are provided timely medical attention. Interviews conducted and records reviewed revealed the facility failed to report R1’s transport to the hospital via the 9-1-1 call and will be addressed in a separate report. Based on interviews conducted and records reviewed, the allegation that Staff did not assist resident with obtaining care in a timely manner is Unsubstantiated at this time. On the allegation, Staff did not observe resident for a change in condition: Reporting Party voiced concern that staff did not recognize a change in condition when Resident 1 (R1) developed a Urinary Tract Infection (UTI). Interviews conducted and records reviewed revealed R1 understands and maintains their medical conditions with assistance from family and personal advocates as well being responsible for their own medical decisions. Interviews conducted and records reviewed revealed R1 has personally contacted their Medical Doctor (MD) when medical issues arise. Interviews conducted and records reviewed revealed R1 contacted their MD when R1 developed a UTI and R1’s MD prescribed medications for treatment. Based on record review and interviews conducted, the allegation Staff did not observe resident for a change in condition is Unsubstantiated at this time. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, May 6, 2026 · control 29-AS-20260427163728

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20260427163728. The Case Management visit is being conducted to address CCLD’s concerns that were observed during the course of the investigation. LPA Kontilis met with Administrator Robert Glock and explained the purpose of the visit. Long Term Care Ombudsman Diane See participated in the visit. During the complaint investigation, interviews conducted and records reviewed revealed 9-1-1 was called for Resident 1 (R1) when R1 experienced an unwitnessed fall. Records reviewed and interviews conducted revealed the facility failed to submit a Serious Illness/Serious Injury report to CCLD regarding R1’s unwitnessed fall. Administrator Glock acknowledged there is no record of an incident report being sent to CCLD regarding a fall R1sustained resulting in 9-1-1 being called and R1 was transferred to the local hospital. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Civil Penalty Assessed. Copy of report and Appeal Rights issued via email.the state’s words, verbatim · CDSS document, May 6, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: May 8, 2026

87211(a)(1)(D) A written report shall be submitted to the licensing agency...within seven days…(D) Any incident which threatens the welfare, safety or health of any resident… This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when the facility did not submit Serious Illness/Injury report when 911 was called for R1 due to an unwitnessed fall which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: Licensee agrees to conduct an audit of all internal incident reports from any incidents that may have occurred since 1/2026. Licensee agrees to conduct an inservice training to review regulations, practice and policy with all care staff. Licensee agrees to submit a plan of when the audit will be conducted via email to LPA. Licensee agrees to submit inservice training plan including description of training, date(s) training to be held, and first and last names of all staff required to attend. Inservice training plan will be sent to LPA via email.

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 revealed on 1/15/2026 at 9:00 pm R1 refused self-administration of Clonazepam 0.5mg tablet. Record review revealed R1 reported to their responsible party via text message on 1/15/2026 at Please continue to 9099-C, Pg 2. Substantiated 9:13 pm they had just received their medications, but it was the incorrect amount, noting it was 0.25 mg instead of 0.5 mg. R1 indicates their medications were updated after the hospital visit, but this information could not be confirmed. Additionally, text messages revealed on 2/10/2026 R1 was not provided their morning dose of Effexor as of 8:00 am. However, the MAR shows the medication was provided at 7:00 am. Interviews conducted revealed on separate occasions, staff attempted to deliver R1’s Gabapentin 100mg medication for self-administration, but R1 refused the medication because the staff was providing the medication too early. However, this could not be confirmed by documentation. On 4/3/2026, the facility provided incident reports indicating medication errors for three residents that were discovered after a medication audit for all residents in the facility who rely on facility personnel to manage their medications. Resident 2 (R2) had multiple medication discrepancies after returning from a Skilled Nursing Facility, and as a result of insurance and billing issues related to the medication. Resident 3 (R3)’s medication order received on 2/25/2026 to discontinue Celebrex 200mg twice daily was not implemented, and R3 continued to receive the medication until 3/31/2026. Resident 4 (R4)’s medication order for Methocarbamol 750mg was updated to four times daily for 3 days for increased back pain from 3/18/2026 to 3/20/2026. However, the order was written in the MAR as a PRN order, so the medication was not given as prescribed. Based on interviews conducted and records reviewed, the allegation that Staff did not properly assist with the self-administration of medications is Substantiated at this time. On the allegation, Staff do not refill resident’s medication prescription in a timely manner: It has been alleged that Resident 1’s (R1’s) medications were not refilled causing R1 to miss their prescribed medications. Record review revealed Resident 1 (R1) reported to their responsible party via text message on 2/10/2026 at 8:00 am, “No anti depressant pill Effexor this am…told ‘Staff’ to talk to ‘Staff’ or look for one. Again a screw up. Without the most important meds I’ll go into a depression…just thinking about it gets me depressed and sweaty”; Responsible Party replied, ‘Dr.’s office is going to call…and take it to you as soon as it’s ready’; R1 replied ‘Staff” found two 75mg’… Review of R1’s Medication Administration Record (MAR) revealed the following: R1 was prescribed Pantoprazole Sodium F/C 40mg tablet 1 tab by mouth twice daily before breakfast and dinner. Start date: 12/12/2025; End: 3/15/2026. LPA reviewed R1’s Medical Administration Record (MAR) for January 2026, February 2026 and March 2026. Record review of R1’s MAR revealed staff initialed “Medication Not Available” in January, February, and March of 2026. LPA noted January 2026 MAR reveals “Medication Not Available” verified by initials as follows: one (1) entry noted by Staff 1 (S1); thirteen (13) entries noted by Staff 2 (S2); Please continue to 9099-C, Pg 3. one (1) entry noted by Staff 3 (S3); two (2) entries noted by Staff 4 (S4); five (5) entries noted by Staff 5 (S5); six (6) entries noted by Staff 6 (S6); one (1) entry by Staff 7 (S7); and eight (8) entries noted by Staff 8 (S8). LPA noted February 2026 MAR reveals “Medication Not Available” verified by initials as follows: fifteen (15) entries noted by S2; five (5) entries noted by S4; three (3) entries noted by S5; three (3) entries noted by S7; three (3) entries noted by S8; and six (6) entries noted by S9. LPA noted March 2026 MAR reveals “Medication Not Available” verified by initials as follows: seven (7) entries noted by S2; two (2) entries noted by S4; three (3) entries noted by S5; two (2) entries noted by S8; and 1 entry noted by S9. R1 was prescribed Triamterene-Hydrochlorothiazide 37.5-25mg capsule by mouth, start date 1/7/2026. MAR notes “Condition: Essential (primary) hypertension. LPA reviewed R1’s Medical Administration Record (MAR) for January 2026, February 2026, and March 2026. Record review of R1’s MAR revealed staff initialed “Medication Not Available” in January, February, and March of 2026. LPA noted January 2026 MAR reveals “Medication Not Available” verified by staff initials as follows: four (4) entries noted by S2, and five (5) entries noted by S5. LPA noted February 2026 MAR reveals “Medication Not Available” verified by staff initials one (1) entry noted by S2; and one (1) entry noted by S5. R1 was prescribed Valacyclovir F/C 500mg tablet by mouth twice daily. Start date 1/12/2026, end date 2/2/2026: MAR states Herpesviral infection, unspecified. LPA reviewed R1’s Medical Administration Record (MAR) for January 2026 and February 2026. Record review of R1’s MAR revealed staff initialed “Medication Not Available” in January 2026 and February 2026. LPA noted January 2026 MAR reveals “Medication Not Available” verified by staff initials as follows: two (2) entries noted by S2, one (1) entry noted by S5, three (3) entries noted by S6, and two (2) entries noted by S8. LPA noted February 2026 MAR reveals “Medication Not Available” verified by staff initials as follows: one (1) entry by S2; one entry by S5; one (1) entry by S7, and one (1) entry by S9. Based on interviews conducted and records reviewed, the allegation that staff do not refill resident’s medication in a timely manner is Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies was cited (refer to LIC 9099-D): Exit interview conducted. Copy of report and Appeal Rights issued via email.the state’s words, verbatim · CDSS document, May 5, 2026 · control 29-AS-20260309111520

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: May 7, 2026

Incidental Medical and Dental Care: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on record review and interviews conducted, the licensee did not comply with the section cited above when staff did not give medications as prescribed for multiple residents, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: Licensee agrees to submit written Plan in Place to ensure medications are administered per Physician's orders including changes and/or updates to medications and/or residents' changes in condition. Written plan will be submitted to LPA via email no later than due date (5/7/2026).

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 7, 2026

Incidental Medical and Dental Care: The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review and interviews conducted, the licensee did not comply with the section cited above when R1’s MAR repeatedly noted “Medications Not Available” consecutively in January 2026, February 2026, and March 2026 posing an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: Licensee agrees to submit written Plan in Place to ensure timely refills, changes in medication orders, and resident's change of condition. Written plan will be submitted to LPA via email no later than due date (5/7/2026).

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 Substantiated LPA asked to audit R1’s double locked Narcotics next. Staff opened the Narcotics and LPA was unable to find the order of bubble pack PRN medication for R1’s Hydrocodone. According to records the pharmacy had delivered R1’s medication to the facility on 03/13/2026 at 1:12am and the NOC shift Staff 1 (S1) at the front desk signed for the delivery. The medication was never logged by the medication technician (Med-Tech) after delivery of the medication. The records for R1’s delivery on 03/13/2026 medications were never logged into medication room. R1’s medication Hydrocodone appeared to be missing or stolen as it could not be found in the facility after being delivered and was never input into R1’s records. The facility did report to local Law Enforcement, and a case number was assigned for the missing narcotics. LPA reviewed records for R1’s medications, filled orders and delivered medications. R1’s last medication was delivered by the pharmacy to the facility on 03/13/2026 at 1:12am and Staff 1 (S1) signed for the delivery of a 60 count of bubble packed Hydrocodone PRN medication. R1’s Medication Administration Records (MAR’s) were reviewed from May 2025 through March of 2026. The facility started using a new automated online system for residents’ medication records around summer of 2025. The Wellness Department started using written paper forms to account for the Narcotics usage as they were transitioning to the new system. LPA reviewed all R1's automated online medication records, and all the paper records provided by the facility. LPA discovered that no paper record could be found for October 2025 for the usage of R1’s Narcotic Hydrocodone 60 count of pills. The facility did get the medication based on delivery records and it was input in the automated records of being received. LPA audited records and found that the delivery from October 2025 60 count of Hydrocodone for R1 had records for 25 pills being used by R1 and 35 pills were not accounted for based on those records.R1 ran out of the October Hydrocodone 60 pills count some time in February of 2026 and at that time a new order was delivered on 03/13/2026 for another 60-pill count. A staff interview revealed that R1 had asked for the medication in mid to late February 2026 and the medication had ran out and staff was not sure why it had not been received. Another staff member stated that it had been ordered but the pharmacy needed a new refill from R1’s doctor before the pharmacy would refill the medication, the pharmacy received the new order from the doctor on 03/12/2026 and filled the order and delivered on 03/13/2026. Continued 9099-C Staff did not have an explanation for why R1 had been out of medication for so long and why the medication was not followed up on for refill. In total the facility could not account for 95 of R1’s Hydrocodone medication after LPA’s audit. 60 of the pills were not found and disappeared after delivery and 35 were not documented as given to R1 during that time of transition due to the lost paper record for October 2026. Staff interviews revealed the process of receiving medications was that the pharmacy Omnicare delivered to the facility front desk and the concierge staff would sign for it, then notify the Med-Techs the medication was in and needed to be picked up. Med-Tech staff said medication did not sit for very long at the front desk before it was picked up and processed into the medication system for the residents as they were instructed to pick it up timely. A few staff said the facility has changed the process since LPA’s visit and now the front desk concierge calls the med-tech on duty to come down and sign for the delivery of medications from Omnicare, staff use the delivery inventory sheet to count and then sign directly with the Omnicare delivery service, then the Med-tech’s will take the medications directly to the Wellness Department for logging and locking. Based on the evidence of R1’s missing, stolen or unaccounted for medication this allegation is Substantiated at this time. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, May 5, 2026 · control 29-AS-20260323223249

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 7, 2026

(h)... (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:the state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: Administrator agreed to put a new process in place immediately for handling medications and will train all Wellness staff in mandated reporting, SOC 341 abuse reporting, and all med-tech staff on facility policy procedures for handling medications and train in regulation 87465, provide material used and proof of all staff signatures with an up to date LIC 500 for staffing.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20260030911520. The Case Management visit is being conducted to address CCLD’s concerns that were observed during the course of the investigation. LPA Kontilis met with Administrator Robert Glock and explained the purpose of the visit. During the complaint investigation, interviews conducted and records reviewed revealed Resident 1 (R1) self-admitted into the hospital on 2/20/2026 and returned to the facility on 3/2/2026. On 3/20/2026, an incident occurred wherein R1 was admitted into the hospital as a result of a 9-1-1 call while R1 was out of the facility. After the 3/20/2026 incident, R1 did not return to the facility. As a result of the 3/20/2026 incident, R1 was issued an eviction notice dated 3/21/2026 stating the facility could no longer provide the level of care and/or a safe environment for R1. Record review revealed a copy of the 3/21/2026 eviction letter was not received by Community Care Licensing Division (CCLD) as required in California Code of Regulations (CCR). Administrator Glock acknowledged the eviction letter was sent to R1, however the letterhead of the notice does not bear the full address nor the facility number on the letter. Administrator acknowledged there is no record of the eviction letter being sent to CCLD. Further record review revealed a Serious Illness/Serious Injury incident report was not received by CCLD as required reporting R1’s self-admission into the hospital on 2/20/2026. Administrator acknowledged there is no record of an incident report being sent to CCLD since R1 self-admitted into the hospital on 2/20/2026. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report and Appeal Rights issued via email.the state’s words, verbatim · CDSS document, May 5, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: May 7, 2026

87211(a)(1)(D) A written report shall be submitted to the licensing agency...within seven days…(D) Any incident which threatens the welfare, safety or health of any resident…This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when the facility did not submit Serious Illness/Injury report for R1 who self-admitted into the hospital which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: Licensee agrees to submit a written statement acknowledging CCR 87211 in its entirety. Written statement will be submitted to LPA via email no later than POC due date (5/7/2026).

From the deficiency page — Deficiency type: Type B · Section cited: CCR87224(f) · Plan of correction due date: May 11, 2026

87224(f) Eviction Procedures: 87224(f) Eviction Procedures: A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as facility staff failed to submit an eviction notice to CCLD which posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 5, 2026

Plan of correction: Licensee agrees to submit a written statement acknowledging CCR 872224 in its entirety. Written statement will be submitted to LPA via email no later than POC due date (5/11/2026).

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) De Leon conducted a case manamgent incident on a death report. LPA met with Robert Glock, Administrator and explained the purpose of the visit. LPA received a death report dated 03/22/2026. LPA spoke with administrator and requested the following records: DNR, Death Certificate for R1 with cause of death and any recent medical appointments. Resident did not have DNR. Administrator will request and forward the requested records as soon as possible. Exit interview conducted and copy of report emailed to Administrator.the state’s words, verbatim · CDSS document, Mar 24, 2026

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 conducted with Administrator Robert Glock Please continue to 812-C, Pg 2. Substantiated revealed the water was shut off on Monday, March 9, 2026 at approximately 10:00 pm and turned back on at 5:00 am. Interview further revealed the notices were distributed to residents on March 7, 2026 via hand delivery. Administrator Glock stated staff were informed that an overflow water supply was available to flush toilets if toilets were flushed, however this was not communicated to the residents. Interview conducted revealed the plumbing project was being considered over the last two years. At approximately 12:42 pm, Maintenance Director informed Administrator Glock that hand-washing stations have been ordered and are expected to be delivered to the facility by 2:00 pm today, 3/11/2026. Maintenance Director stated the hand-washing stations were ordered earlier today at approximately 12:10 pm. CCLD’s concerns are that an alternate plan was not in place for accommodations to the residents; hand-washing stations were not provided to the residents prior to the first day of the water shut-off; a more sufficient notice could have been given to residents to include the toilets could be used and they could ask staff for assistance obtaining water to flush them; the communication was unclear about accessing the “SAGE system” if residents needed assistance; and, the facility administrator did not notify or seek guidance from CCLD to ensure healthful accommodations and sanitary conditions were in place. Based on record review and interviews conducted, the allegation that staff did not provide proper accommodations to residents in care is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted, Appeal Rights and copy of this report issued at the time of the visit.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 29-AS-20260309155422

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Mar 10, 2026

87307(d)(2) (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when staff conducted a facility water shut off for six days without clear communication and without healthful and sanitary accommodations which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: Administrator agrees to provide a written statement to LPA that Administrator has personally discussed with residents the following: the location of the hand-washing stations; flushing will be captured by an overflow; they may express any concerns re: the water shut off, and will remind them to press SAGE pendant and request help from care staff if needed. Administrator agrees to offer water bottles, remind residents of juice and water stations available, and remind them that Med Techs have water pitchers on carts, and remind them there are sanitizer stations throughout the building, and will assure them of 5 gal jugs of water for emergencies.

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) Unsubstantiated LPA toured the facility with the Backup Administrator and Wellness Director finding no observable mold. LPA was able to locate where the alleged mold was at a beverage dispenser just inside the entry to the dining room. Both trays were clean with no mold. Staff interviews revealed this area and the trays are cleaned at least twice daily. Residents interviewed stated there are no issues with the cleanliness of the facility or their personal rooms. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated. Exit interview conducted, reports signed, report provided to Backup Administrator Apple Pelare.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 29-AS-20260212121521

Type of visit: Required - 1 Year

At 11:00am, on February 18, 2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection along with another visit type. LPA met with Backup Administrator Apple Pelare, announced who he was and the reason for the visit. LPA conducted a cursory tour of the facility with the Backup Administrator and Wellness Director. This is a three story facility with 121 resident rooms each with a private bathroom. LPA entered the facility at it's main entrance located on the ground floor. Upon entering LPA noted a large lobby space with a reception desk, administrative offices, and multiple areas for residents and guests to sit and visit. LPA noted carbon monoxide detectors located next to the fireplaces in the main lobby. The sprinkler system was tested by Joy Equipment Protection, Inc. on January 20, 2026. LPA was not able to complete the annual inspection and may return at a later time to finish. Exit interview conducted, reports signed, reports and appeal rights provided to Backup Administrator Apple Pelare.the state’s words, verbatim · CDSS document, Feb 18, 2026

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

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 stated that it would not be allowed. Interviews conducted revealed no inappropriate conduct was observed between Please continue to 9099-C, Pg 2. Unsubstantiated staff members by staff or residents. One staff member stated they have not observed “PDA (public display of affection)” between any staff. Although this may violate a facility’s staff policy, no corroborating evidence was obtained to show the staff have been inappropriate in front of residents. Therefore, the allegation that staff engage in inappropriate behavior with another staff member in the presence of residents is Unsubstantiated at this time. On the allegation: Staff does not provide a healthy and safe environment to residents. It was alleged on 11/14/2024, one food server came down sick, but was not allowed to leave due to short staffing. It was alleged ‘instead the server wore a mask and served food’. LPA conducted interviews with staff and residents on 12/24/2024, 12/5/2025, 12/9/2025 and 12/10/2025. Interviews of staff and residents overwhelmingly stated no staff have been observed being at work while being sick. One resident stated they observed staff to be conscious of people coughing and being sick. Staff interviews revealed knowledge of the facility’s sick leave policy and stated they would call their supervisor if they were having symptoms of illness. Based on the interviews conducted, the allegation that the facility staff does not provide a healthy and safe environment to residents in care is Unsubstantiated at this time. On the allegation: Staff withhold food from residents. It was alleged residents who want tray service must request it by 4:00 pm and will not be served if ordered after 4:00 pm. Interviews stated the kitchen closed at 5:50 pm. LPA conducted interviews with staff and residents on 12/24/2024, 12/5/2025, 12/9/2025, and 12/10/2025. Interviews conducted revealed residents are aware of the facility’s dining service’ hours and the time(s) in which they are required to make their tray service request. Interviews revealed the staff are accommodating to the residents with regard to the tray service and the residents understand the parameters of the facility’s dining services’ hours and tray service hours. Interviews revealed that they are satisfied with Dining Services’ efforts to accommodate the residents when there are extenuating circumstances at hand. Staff interviews revealed that when they know a resident and/or residents will be away from the facility outside the Dining Service hours, they will provide for the resident by reserving a meal, or accommodating in some way with a sandwich, fruit, cereal and milk. Administrator stated, if need be, they will ensure a resident has a meal provided either by having something from the kitchen or calling an order to be delivered to the facility. Administrator provided the facility handbook to include the Dining Service Hours and a weekly menu showing Dining Service hours as well as additional meal options. Additionally, Administrator stated the facility conducts Town Hall meetings where dining information is discussed on a regular basis. Based on the interviews conducted and information obtained, the allegation that staff withhold food from residents is Unsubstantiated at this time. Please continue to 9099-C, Pg 3. On the allegation: Staff does not accommodate resident's food needs: It was alleged Resident 1 (R1) returned to the facility from hospitalization with a diagnosis of diabetes and a special diet. It was alleged the executive chef did not follow the special diet and informed the resident to buy their own food. During an interview with Wellness Director on 12/5/2025, Wellness Director confirmed R1 was on a special diabetic diet. Administrator stated the facility does not accommodate special diets such as diabetic preferences, gluten free, kosher diets, etc., unless their diet is specified in a resident’s Physician’s order. Administrator stated although R1 may prefer a “diabetic” diet, the facility is not obligated to accommodate that diet. Administrator further stated the facility menu offers a variety of menu items and alternative choices many of which may be conducive to a resident’s special diet preference. Administrator pointed out the weekly menu dated 11/30/2025 through 12/6/2025 included diabetic preference foods including a fish dish “Catch of the Day”, grilled chicken, eggs, green house salads, fresh fruit, and other such items. During today’s visit, interviews revealed R1 was determined to be “pre-diabetic” rather than diabetic and was provided alternative options from the current menu. Therefore, based on records reviewed and interviews conducted, the allegation that staff does not accommodate resident’s food needs is Unsubstantiated at this time. On the allegation: Staff does not allow resident visitors. It was alleged that a former staff was denied visiting a resident. Administrator stated they do have a policy that staff who have been terminated cannot come into the facility under another agency, such as home health or a private caregiver agency. Administrator stated a former employee came to the facility to work as a private caregiver, and they were informed of the policy. Administrator stated the former employee did not respond well to this information. Administrator stated a responsible party had hired the former employee, but the family preferred a different private caregiver who the family decided to hire. Interviews revealed no resident specifically asked for the former staff to visit and was denied visitation. Administrator stated they understand if a resident requests a specific visitor, even if it conflicts with their internal policy, they need to accommodate the visit in some way. LPA discussed resident visitation rights with the Administrator and emailed the Provider Information Notice (PIN) 25-04-ASC to the Administrator. Based on record review and interviews conducted, the allegation that staff does not allow resident visitors is Unsubstantiated at this time. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Dec 10, 2025 · control 29-AS-20241218153653

Type of visit: Office

On 10/30/2025, an Informal Conference was held at the Goleta Office. In attendance included Licensing Program Manager (LPM) Kelly Burley, Licensing Program Analyst (LPA) Kristin Kontilis, Administrator Robert Glock, and Wellness Director Tina Tran. The purpose of this Informal Conference is to discuss complaint investigation 29-AS-20241001130402. A general compliance review of the facility was also discussed. The facility was licensed on 03/24/2023 and the current census is 101. The Administrative Action process was explained to the licensee representatives, as well as the role of an informal conference. On 10/01/2024, the RO received a complaint alleging facility staff did not answer Resident 1 (R1’s) call button in a timely manner, resulting in the resident sustaining a fracture. R1 required assistance with care needs, and the investigation revealed although Staff 1 (S1) claimed R1’s call for assistance, they did not respond. R1 was unattended to for hours, resulting in R1 falling and sustaining a facial laceration, hematoma, and wrist fracture. During today’s conference, the licensee representatives discussed the strategies they’ve employed in order to maintain compliance with Title 22 Regulations. Licensee representatives discussed measures they had implemented to address changes in condition with R1, additional care monitoring, and other resources to address R1’s needs, particularly overnight. They also discussed additional oversight measures for their signal system, as well as additional trainings on staff communication. Strategies also included monthly medication audits and daily compliance checks with their updated electronic medical record system. The licensee representatives were again notified of the potential for Administrative Action, including a civil penalty of $10,000 for serious bodily injury, which is still under review. Should it be determined that the civil penalty will be issued, the licensee will be notified. Exit interview conducted and copy of today's report was provided to the licensee representatives.the state’s words, verbatim · CDSS document, Oct 30, 2025

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 obtained various documents pertinent to the investigation. From 10:15 am Please continue to 9099-C, Pg 2. Substantiated to 10:50 am, the LPA conducted a brief interview with the Administrator. The LPA informed the Administrator that further investigation would be conducted by the Community Care Licensing Division (CCLD) Investigations Branch (IB) Investigator Johnny Canto. On 10/12/2024, at approximately 9:40 am, Investigator Canto attempted to contact the reporting party; on 10/21/2024, from approximately 8:00 pm to 9:59 pm, conducted interviews with the Administrator and facility staff; on 10/22/2024, from approximately 8:10 am to 8:55 am, with residents and Resident 1 (R1); on 11/05/2024, from approximately 2:15 pm to 4:00 pm, with staff and the Administrator, and on 11/06/2024, at approximately 10:56 am, with former staff. In addition, Investigator Canto reviewed Santa Barbara Cottage Hospital medical records and facility file documents related to the investigation. The Santa Barbara Police Department (SBPD) also received a report of neglect and conducted a visit to the facility on 10/01/2024. A copy of the SBPD Report #2024-51627 was requested. A review of R1’s facility file documents revealed that R1 was admitted to the facility on 01/28/2024. According to the resident appraisal, dated 01/28/2024, R1’s diagnoses included A-FIB, breast cancer, endometrial cancer, GERD, Hyperlipidemia, and Hypertension. The appraisal indicated R1 did not have a current history of disruptive, aggressive, verbal, or socially inappropriate behavior, depression, anxiety, or mood disorder. No history of hallucinations or delusions. R1 can express self verbally, able to express pain verbally and with facial grimaces. R1 requires a supportive ambulatory device (walker). R1 requires total extensive assistance with transferring. R1 is considered at risk for falls, and appropriate interventions should be implemented on the service plan and a negotiated risk agreement completed. R1 will wear a wireless pendant for emergency calls. R1 requires physical assistance with toileting task; escorting transferring to the toilet and may need assistance in the use of incontinence supplies. Staff interviewed indicated R1 had sustained “several falls” and was a known fall risk. Staff interviewed also stated they believed R1 needed a higher level of care. Staff interviewed indicated if they claim a call button, they must respond, regardless of how many times a resident calls. Other staff interviewed indicated R1 pressed their call button so frequently, some stopped responding to R1’s calls. Additionally, Investigator Canto tested a resident’s pendant at random in the facility, and no staff responded after twenty (20) minutes of waiting. A review of the Santa Barbara Cottage Hospital medical records revealed R1 arrived at the hospital on 08/27/2024 at 11:25 pm with a chief complaint of head injury due to an unwitnessed fall. The injuries were noted as right facial 3 cm laceration lateral to right eye and hematoma over right scalp. R1 also appeared to Please continue to 9099-C, Pg 3. have a right wrist deformity and swelling. An x-ray confirmed a midshaft radius (wrist) fracture which required surgery. R1 had open reduction internal fixation (ORIF) surgery on 08/31/2024 and was discharged back to the facility on 09/01/2024. The Department’s investigation revealed that on 08/27/2024, R1 called for assistance through the facility’s call system (Sage Pendant), for assistance with the restroom. Staff #1 (S1) who worked the PM shift (2:30 pm to 11:00 pm) claimed the call for assistance; however, S1 did not attend to R1. When staff did not respond, R1 attempted to use the restroom on their own, fell, and hit their head. The last time R1 was seen without incident was at approximately 9:00 pm. At approximately 11:00 pm, at the end of the PM shift, S1 cleared the call for assistance without verifying the wellness of R1. Staff #2 (S2), who worked the overnight shift (11:00 pm to 6:00 am), received a call for assistance from R1. Upon entering R1's bedroom, S2 discovered R1 on the floor, with dried blood on the right side of the head. 911 was called and R1 was transported to the hospital. R1 sustained a facial laceration and midshaft radius fracture. A review of the Sage Pendant call system noted R1 called for assistance approximately five hundred (500) times. S1 was interviewed and stated S1 failed to assist R1 due to forgetting they had claimed the call for assistance and was focused on S1’s other duties. The facility failed to respond to R1’s calls for assistance and neglected R1’s care. Therefore, the allegation “Staff did not answer resident's call button in a timely manner, resulting in resident sustaining a fracture.” is Substantiated at this time. A $500 immediate civil penalty is assessed today. Administrator Glock was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Apr 14, 2025 · control 29-AS-20241001130402

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 16, 2025

87468.2(a)(4) Additional Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) 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 evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff did not ensure R1’s call button was responded to timely, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2025

Plan of correction: Licensee agrees to submit a plan on how residents will receive timely assistance. Assistance Plan will be submitted via email to LPA Kontilis no later than 4/16/2025. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1).

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Jan 15, 2025

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. 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 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.the 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 returned to the facility and was placed on hospice. Witness originally stated they observed the “sores,” then later stated they did not personally observe them. Please continue to 9099-C, Pg 2. Unsubstantiated Witness interviewed stated R1’s skin could have been breaking down due to their health decline. LPA reviewed R1’s physician’s report dated 2/21/2024, which states R1 had diagnoses including stage IV colorectal cancer, adrenal insufficiency, mild cognitive impairment, and hypothyroidism. The physician’s report also indicates R1 had some bladder impairment, no bowel impairment, no history of skin breakdown, is able to follow instructions and communicate needs. It also states R1 needs assistance with bathing, should have some supervision toileting but is able to care for own needs, and needs verbal prompting to dress/groom self. The physician’s report does not mention any pressure injuries or wounds. R1’s pre-admission appraisal dated 4/10/2024 states R1’s overall skin condition and skin color is “normal,” and states there are no active wounds or areas of active skin issues. The appraisal states R1 is independent with mobility, needs limited assistance with transferring, and is independent in repositioning. R1 requires minimal assistance with bathing but may require reminders, set up or standby assistance; requires minimal assistance with grooming/personal hygiene and dressing but requires verbal reminders or set up assistance; requires minimal assistance with toileting including verbal prompts and may ask for standby assistance, and states the resident is usually continent but may use adult briefs. The appraisal also states the resident has been educated on how to use their call button system for staff assistance, and R1 was coherent and able to communicate. The appraisal does not indicate R1 had any pressure injuries or wounds. LPA reviewed an internal incident report dated 4/21/2024 that R1 had a sliding fall when trying to get into a car. Staff notified R1’s doctor of the fall. LPA reviewed an internal incident report dated 4/26/2024 that indicated on 4/26/2024 R1 had an episode of vomiting, complained of back pain, and was sent to the hospital. The incident reports indicate staff were checking on R1. Interviews with staff revealed that facility caregivers checked on R1 multiple times a day and assisted R1 with activities of daily living (ADLs) as needed. R1’s discharge paperwork from the hospital dated 5/8/2024 notes diagnosis of principle pyelonephritis on 4/26/2024. The discharge paperwork does not indicate any pressure injuries, wounds or sores on R1’s skin. The discharge paperwork does state in addition to the pyelonephritis, R1 had macrocytic anemia. Interviews with administrator and wellness director revealed R1’s anemia led to increased weakness and pale skin. Wellness director, who is an RN, also stated if R1 had sores, they could have taken longer to heal due to the Anemia. Please continue to 9099-C, Pg 3. R1 was discharged from the hospital back to the facility and placed on hospice. R1’s responsible party chose to have private caregivers come in and provide additional care to R1, along with hospice. Someone on R1’s care team was present with R1 at all times from 5/8/2024 until they passed away. In addition, Administrator and Wellness Director stated facility staff also checked on R1 and checked in with R1’s private care team multiple times per day. R1’s hospice care plan dated 5/8/2024 and updated 5/11/2024 does not indicate R1 had any pressure injuries, wounds or sores. R1 passed away on hospice and was unable to be interviewed. Based on the investigation, R1 only required minimal care assistance when they moved into the facility and was able to communicate their needs to staff. R1 was not officially diagnosed with any pressure injury, sore or wound per hospital and hospice paperwork. There was insufficient evidence to prove the allegation Facility staff did not meet resident's needs. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, May 29, 2024 · control 29-AS-20240514113058

Type of visit: Case Management - Other

On 03/06/2024, Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Case Management site visit with the purpose of following up on an immediate exclusion served to Staff #1 (S1) via certified mail. LPA met with Robert Glock, Executive Director and Karolyn Sorenson, Regional Operations Specialist for a Confirmation of Removal visit. An immediate exclusion order for S1 was dated February 2, 2024, and provided via certified mail. S1 is excluded from any care facility licensed by the Department and is required to be removed from the facility. Administrator stated that S1 has not worked at the facility since 4/22/2018; however, S1’s fingerprint clearance was not disassociated and S1’s fingerprints carried over to the current facility license. During this visit, the Administrator provided LPA with a copy of the current personnel roster to verify S1 is not working at the facility. During today’s visit, S1 was not observed in the facility at this time. No citations issued during today's visit. Exit interview was conducted with Administrator; a copy of the report was issued at the time of the visit.the state’s words, verbatim · CDSS document, Mar 6, 2024

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Feb 27, 2024

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 the resident would not be going back to Garden Court but remaining at their current facility. R1’s family member (FM1) and friend came out to talk with Administrator who then called the Wellness Director. (Continued on 9099-C) Unsubstantiated Both Administrator and Wellness Director stated they needed to speak to the resident for confirmation. Wellness Director stated they asked if R1 had a POA and no one answered. FM1 stated they became R1's POA when they signed the Hospice admission. Wellness Director asked for a copy and never received it. Both Wellness Director and Administrator stated R1 was responsible for themselves and had no Responsible Party or POA. LPA reviewed R1’s Admission Agreement and Emergency Contact paperwork. LPA observed there to be no responsible party listed on R1’s Admission Agreement. LPA observed no POA paperwork in R1’s file. LPA observed R1’s emergency contact to be FM2. Administrator stated on 10/2/23 they did ask the company picking up R1’s equipment to wait so they could confirm with the resident they were not coming back. Administrator stated they were under the impression R1 was returning and was surprised they were picking it up. Once Administrator spoke with R1’s family and stated they made the decision for R1 not to return they allowed the company to take the equipment and stated to LPA it was about an hour later. Administrator stated on 10/6/23 the family came to move out R1’s things and they removed all of R1’s belongings. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of report issued.the state’s words, verbatim · CDSS document, Dec 11, 2023 · control 29-AS-20231004170559