Mission Villa

Allegation investigated: Licensee financially abused a resident in care.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to issue final findings on the above-stated allegation. LPA met with Administrator Emily Gerr and explained the purpose of the visit. On 10/28/2025 from 10:23 am to 3:40 pm, LPA Kontilis conducted an initial complaint visit to obtain documents and conduct interviews. On the allegation: Licensee financially abused a resident in care: It was alleged the licensee financially abused Resident 1 (R1), by removing money from their account and safety deposit box. LPA interviewed the reporting party, who stated the licensee had a preexisting friendship with R1 and the licensee became R1’s Power of Attorney (POA) in August 2023. During today’s visit, Administrator confirmed the Licensee had a preexisting friendship with R1 and became their POA for medical and financial. Administrator confirmed Licensee helped care for R1 for approximately Please continue to 9099-C, Pg 2. Unsubstantiated two years while R1 resided in a skilled nursing facility, and R1’s health declined. Records reviewed and interviews conducted revealed R1 moved into the facility in the evening of 3/16/2025, and R1 passed away in the early morning of 3/17/2025. Based on the information obtained during the investigation, the allegation is Unsubstantiated at this time. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 29-AS-20251021125447

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required Inspection of the facility. At the time of arrival, there were two (2) care staff, one (1) housekeeper, and (1) Food Service Manager on duty and thirteen (13) residents in care. LPA met with Emily Gerr, Administrator and explained the purpose of the visit. Entrance interview conducted: The facility is a one-story Residential Care Facility for the Elderly (RCFE) with a capacity of fifteen (15) residents. The facility is a memory care facility for residents with a dementia diagnosis. The facility has a fire clearance for fifteen (15) non-ambulatory residents and a hospice waiver for six (6) residents. There are five (5) residents currently on hospice. LPA toured the facility with Administrator Emily Gerr. The facility consists of a large common area used for dining and activities. Equipment and supplies are kept in a locked cabinet located in the hallway of the facility. Residents participate at will in activities such as board and card games, arts and crafts and walks around the facility. LPA observed a comfortable room temperature throughout the facility. LPA observed the living room and dining area to be neat and clean. The kitchen area consists of two sinks, a dishwasher, refrigerator, freezer, stove/oven, microwave, coffee makers, toasters, fresh juice machine, mixer/blender, waffle iron and two dishwashing machines. LPA observed a sufficient amount of perishables for two days and non-perishables for seven days available to residents in care. Please continue to 809-C, Pg 2. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors, and floor coverings were checked. There are three (3) fire extinguishers on the premises last serviced on 3/31/2025. There are approximately four (4) smoke alarms and one (1) carbon monoxide detector all in good working order. LPA reviewed residents records and noted on file are Emergency face sheets, Admission Agreements, Appraisals/Re-Appraisals, Needs and Services Plans, and health screenings. LPA noted one resident’s admission agreement was unsigned and one resident does not have a current admission agreement on file. Technical violation issued. LPA reviewed personnel records and noted not on file are verification(s) of staff trainings and/or orientations of six out six staff members. LPA noted all staff members have current First Aid/CPR certification, current health screenings, and background clearance records. Due to time restraints, LPA will return at a later date to continue the inspection. 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 at the time of the visit.the state’s words, verbatim · CDSS document, Jan 28, 2026

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide privacy to resident when changing resident. Due to lack of supervision, resident pushed another resident. Staff did not treat resident with respect. Staff had resident sleeping in living room. Staff charged resident for toilet paper. Staff did not notify the authorized representative of move. Improper eviction. Staff did not refund resident.

At 1:00pm on 01/22/2026, Licensing Program Analyst (LPA) Jeffries conducted a subsequent complaint visit to issue final findings on the allegations above. LPA met with Administrator Emily Gerr and explained the purpose of the visit. On 5/2/2025 from 11:40am to 3:00pm, LPA Kontilis conducted an initial complaint visit to obtain documents and interview staff and administrator. LPA conducted interviews with R1 on 5/28/2025 at 11:05am and 5/30/2025 at 11:13am. LPA Jeffries interviewed administrator on 01/15/2026 at 1:00pm. On the allegation: Staff did not provide privacy to resident when changing resident. It was alleged Resident 2 (R2) was not provided privacy when staff changed R2, and other residents watched. On 01/22/2026, LPA Jeffries conducted interviews with Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), and Staff 4 (S4). S1-4 all stated that residents are not changed in common areas. CONTINUED on LIC-9099-C Unsubstantiated S1-4 all stated that rooms with dual occupancy, residents being changed are done with door closed and when resident roommate in not in the room as much as possible. On 01/15/2026, LPA Jeffries conducted an interview with Administrator who stated that all staff are up to date on training of resident rights and treat all residents with dignity and respect according to their training. LPA observed all staff training to be current, including resident rights training. On 01/15/2026, LPA Jeffries did not observe any staff disregarding resident privacy. At this time there is not enough evidence to support the allegation of, “Staff did not provide privacy to resident when changing resident” and is unsubstantiated at this time. On the allegation: Due to lack of supervision, resident pushed another resident. It was alleged R1 told another resident not to watch staff change R2, and as a result the resident pushed R1. On 01/15/2026 LPA Jeffries conducted an interview with Administrator who stated that there has only been one incident at the facility where a resident pushed another resident on 02/22/2025, where staff were present. LPA observed Incident Report (LIC-624) dated 02/22/2025 indicates staff attempted to intervene and another staff present. On 01/15/2026, LPA Jeffries conducted interviews with S1-4 who all indicated that they feel there is always enough staff to meet residents’ needs. S1-4 all stated that they recalled only one incident where resident pushed another resident, and all S1-4 identified the described incident dated 02/22/2025. On 01/15/2026, LPA Jeffries observed enough staff present during the visit to meet current residents’ needs. Based on interviews documentation and observations, number of staff present that was documented, at this time there is not enough evidence to support the allegation of, “Due to lack of supervision, resident pushed another resident.” and is unsubstantiated at this time. On the allegations: “Staff did not treat resident with respect.” and “Staff had resident sleeping in living room.” It was alleged staff made R1 pick up things and made fun of the resident and staff started making R1 sleep in the living room. Both R1 and R1’s RP stated R1’s roommate screamed all night. On 01/15/2026, LPA Jeffries conducted an interview with Administrator who stated that all staff are up to date on training of resident rights and treat all residents with dignity and respect according to their training. LPA observed all staff training to be current, including resident rights training. On 01/15/2026, LPA Jeffries did not observe any staff disregarding resident privacy. Administrator stated that R1 had never slept in the living room and staff had to often redirect R1 to bed. Administrator stated that staff always treat residents with dignity and respect and would not make fun of the residents. CONTINUED on LIC9099-C On 01/15/2026, LPA Jeffries conducted interviews with S1-4 all who stated they have training in residents’ rights and personal rights. S1-4 all stated that they have never made fun of a resident and have not wittiness any other staff make fun of a resident. On 01/15/2026, LPA Jeffries observed all staff treating residents with dignity and respect. Based on interviews, training documentation, and observation there is not enough evidence at this time to support the allegations of, “Staff did not treat resident with respect.” and “Staff had resident sleeping in living room.” and are both unsubstantiated at this time. On the allegation: Staff charged resident for toilet paper. It was alleged staff made R1 pay for toilet paper. LPA reviewed invoices for R1 while they lived at this facility. There are no invoices for toilet paper and no indication R1 paid for toilet paper. The admission agreement states toilet paper will be provided to residents as part of the services. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated at this time. On the allegation: Staff did not notify the authorized representative of move. It was alleged that R1’s RP was not told R1 was moving to another facility associated with the Administrator. LPA reviewed a 30-day notice of intent to vacant for R1 dated 04/18/2025 and signed by R1. The 30-day notice is required per R1’s signed admission agreement. On 01/15/2026, LPA Jeffries conducted an interview with Administrator who stated that, “R1 was undergoing medical treatment that made R1 weak, however, R1 did not have a power of attorney and R1 moved at R1’s request.” LPA Jeffries observed R1’s LIC-602 (Physicians Report) that stated that R1 was capable of making their own decisions. Additionally, LPA observed a “Voluntary Consent to reside in a Secured Perimeter Unit.”, this document was singed by R1 on 04/18/2025. At this time there is not enough evidence to support the allegation of, “Staff did not notify authorized representative or move.” and is unsubstantiated at this time. On the allegation: Improper eviction. It was alleged staff made R1 move to another facility associated with the Administrator. LPA reviewed a 30-day notice of intent to vacant for R1 dated 04/18/2025 and signed by R1. The 30-day notice is required per R1’s signed admission agreement. R1 provided a written 30-day notice of their intent to move, and there is no evidence to show an eviction notice should have been issued to R1. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated at this time. CONTINUED on LIC9099-C On the allegation: Staff did not refund resident. It was alleged R1 was not provided a refund, even though R1 moved to another facility associated with the Administrator. Records show R1 lived at the licensee’s other facility Mission Gardens at first, which uses the same billing and rates as this facility. Records show room and care from 2/26/2025 to 3/28/2025 cost $6200. Records show the prorated room and care rate for 3/29/2025 and 3/20/2025 cost $306.54. R1 issued a 30-day notice on 3/11/2025 and moved from Mission Gardens to this facility. Records show room and care from 4/1/2025 to 4/30/2025 were $6200. All amounts were paid. R1 issued a 30-day notice on 4/18/2025 and moved to a different facility affiliated with the Administrator but not owned by her. No refund was issued after R1 moved out, but R1 was not charged for a full 30-days from the date of the notice. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated at this time. Exit interview, report read and report provided.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 29-AS-20250501111925

Type of visit: Case Management - Other

At 10:57am on 01/15/2026, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to follow up on an investigation visit from complaint (29-AS-20250501113652) on a separate report. Upon entering the facility LPA was let in by housekeeping staff and directed to the rear of the facility after requesting to speak to the facility Administrator Emily Gerr. LPA walked the hallway unaccompanied to the directed area where Administrators office is located. When LPA walked in the the common TV room LPA noted that the adjacent laundry room door was open and there were no staff. LPA called out "Hello" to call for staff without any response. LPA then determined that there were 8 residents unattended within feet of the open laundry room door. LPA look in the laundry room and noted that a resident (R1) standing in the laundry room to the side swaying near the wall out of sight from the door way. LPA asked R1 if they were ok and wanted to come out of the laundry room. LPA noted that R1 did not verbally respond and then leaned closed to the inside of the laundry room wall. LPA told R1 "its ok, Ill get a staff here." LPA noted a staff (S1) in the back side of the facility kitchen leaning on the counter looking at their cell phone. LPA commented to S1, "Can you please come get this unattended Resident out of the laundry room." S1 replied, "No, I can get a caregiver to come get (R1)". LPA waited by laundry room until two other staff (S3, and S4) attended to R1. LPA contacted Administrator by phone and requested Administrator to come to the facility as soon as possible. Administrator arrived approximately 10 minutes later. Administrator and LPA both observed a gallon jug of bleach and approximately 30 count of "tide-pods" in a box in an unsecured floor cabinet. LPA conducted an interview with S1 who stated, "S3 had gone to get a muffin, and that is why no one was present at the time your (LPA) saw S1." Based on observations and interviews a citation is issued for storage of items that could pose a danger to residents in care (87309(a) Exit interview, report signed and report provided.the state’s words, verbatim · CDSS document, Jan 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Jan 29, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met by evidence of bleach and "tide-pods" being unsecured and in access to resident in care, which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Administrator secured potentially hazardous items during report visit, Updated the lock on laundry room door and will conduct an hour training for all staff on safe environments for residents on or before 01/29/2026 and will report to LPA on or before 01/29/2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management incident visit to the facility. On 10-15-2025, LPA Kontilis received a telephone call from Administrator Emily Gerr and Licensee Lisa Gerr requesting guidance from LPA Kontilis regarding an incident that occurred in the facility. The date of the incident was not stated. Licensee Lisa Gerr stated a resident (Resident 1/R1) has alleged that a staff member (Staff 1/S1) punched/hit R1 while conducting a brief change with R1. Licensee Gerr stated this was an unusual allegation as S1 has worked at the facility for a while and Licensee believes this is out of character for S1. Licensee stated while an internal investigation looking into the matter is currently being conducted, S1 is on administrative leave. Licensee inquired as to when S1 can return to work once the investigation has been completed. LPA responded by saying that her questions cannot be answered until further information is obtained and a Report of Suspected Dependent Adult/Elder Abuse (SOC341) is submitted to CCLD. On 10/23/2025, CCLD received SOC341 Report of Suspected Dependent Adult/Elder Abuse from Santa Barbara Police Department stating on 10/15/2025, Santa Barbara Police Officer McGowan, Badge #27543, responded to a telephone call from Administrator Emily Gerr. Administrator Emily Gerr stated R1 told her that S1 punched R1 and R1 no longer wanted to live in the facility. During today’s visit, LPA obtained documents pertaining to the incident and conducted an interview with Administrator. R1 and S1 were unavailable at the time of the visit. Administrator Emily Gerr stated on 10/16/2025, Gerr submitted SOC341 Report of Suspected Dependent Adult/Elder Abuse to CCLD and Long Term Care Ombudsman (LTCO) via “fax app” on her mobile phone. Please continue to 809-C, Pg 2. Gerr further stated she assumed the fax was received but was surprised that no one had gotten back to her about the incident. LPA confirmed with Administrator Gerr that the SOC341 report was not received by CCLD until 10-23-2025 via an outside agency. Due to time restraints, LPA will return at a later date to continue the investigation. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Oct 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 28, 2025

87211 Reporting Requirements.(a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement is not met as evidenced by: Based on interview conducted, the licensee did not comply with the section cited above as the licensee did not submit within seven (7) days a written report of suspected adult/elder abuse which poses an immediate health and safety risk to resident(s) in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Administrator agrees to submit the original and revised SOC341 Report of Suspected Dependent Adult/Elder Abuse no later than end of business day, 10/28/2025.

Allegation investigated: Staff are not assisting residents with personal care.

Licensing Program Analyst (LPA) Kontilis conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Emily Gerr, Administrator and explained the purpose of the visit. During the investigation, LPA conducted an initial visit on 9/30/2024 from 1:00 pm to 2:30 pm, where LPA conducted interviews and obtained relevant documents. LPA conducted additional interviews on 9/30/2024, 10/1/2024, 10/22/2024, 10/23/2024, and 11/19/2024. On the allegation: Staff are not assisting residents with personal care. It was alleged that residents are not receiving assistance with dental care. One visitor interviewed stated plaque on the bottom teeth of residents was visible and some residents stated their teeth were not being brushed. Please continue to 9099-C, Pg 2. Substantiated Care notes provided by the Administrator showed one resident refusing all oral hygiene, and after discussing refusals with the family, a care meeting was held to explore strategies. The notes state the resident will be encouraged to engage in teeth brushing, but their right to refuse will be respected. Oral hygiene will be offered at alternate times when a refusal occurs—adapting to the resident’s preferences and comfort. No other care notes for September 2024 indicate other residents refused teeth brushing. Staff interviewed stated some residents refuse teeth brushing. Staff indicated they do not keep a written log of residents refusing teeth brushing but make additional attempts. When staff were asked about the morning routine and how they care for residents in the morning, some staff mentioned brushing their hair and washing their face, but did not mention teeth brushing. When prompted to discuss teeth brushing, staff stated if the refusal for teeth brushing is consistent, they will notify the families but would not necessarily notify them if they refuse for an hour and then they are able to brush the teeth at another time. One staff stated a resident’s teeth were brushed twice a day, and another indicated some residents have no issues with getting their teeth brushed. One resident interviewed stated “They have not been brushing my teeth.” Resident’s responsible party confirmed the resident has said that they are not getting their teeth brushed. Another resident stated their teeth are brushed once per week. One resident interviewed stated they had not brushed their teeth since last week. Another responsible party stated their main issue regrading personal care was teeth brushing and it had been an issue for quite some time. The responsible party stated they asked families/visitors of other residents, who also confirmed other residents were not getting their teeth brushed. One responsible party stated if they notice the teeth are not being brushed, they say something to the staff; and the care had improved after bringing up concerns. Responsible party stated staff indicated it was difficult because the resident did not know to spit out the toothpaste due to their dementia. Responsible party stated the breath was really bad, and they bought toothpaste that was non-toxic. Based on the information obtained, the allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D): Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit.the state’s words, verbatim · CDSS document, May 16, 2025 · control 29-AS-20240927093414

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: May 23, 2025

87468.2(a)(4)…Residents…shall have all of the following personal rights: 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 was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when they did not ensure residents received proper oral hygiene assistance, which posed a potential risk to residents in care. health and personal rights.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: Administrator agrees to submit a written plan that discusses how residents’ oral hygiene needs and care needs will be met.

Allegation investigated: Facility increased resident’s rate without proper notice.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Emily Gerr, Administrator and explained the purpose of the visit. During the investigation, LPA conducted an initial visit on 1/17/2024 from 10:00 am to 4:00 pm, where LPA interviewed staff and residents and requested documents; LPA also conducted additional interviews by phone with relevant parties including responsible parties and witnesses. On the allegation: Facility increased resident’s rate without proper notice. It was alleged the administrator increased Resident 1's (R1’s) rent by $1,000 without proper notice. R1’s responsible party indicated when R1 moved in, they did not receive a copy of the admission agreement they signed despite asking for a copy for months. Per the verbal agreement when R1 moved in, R1’s total rent was $7,000, and incontinence supplies would be provided through hospice. After providing the initial $7,000, the licensee then asked for a “preadmission” fee of $3,000 that was not verbally disclosed initially, nor through writing since the responsible party had not received a copy of the admission agreement. Despite this, the responsible party paid the fee. Please continue to 9099-C, Pg 2. Substantiated In December 2023, the licensee emailed R1’s responsible party to notify them the rent would be increased from $7,000 to $8,000 per month, due to a higher level of care needed. However, R1 had not had any increase in the higher level of care since moving into the facility, and no reappraisal was completed. R1’s responsible party also noted despite asking for a copy of the admission agreement for months, they had not received a copy. R1’s responsible party continued to pay $7,000 for the care, and the licensee attempted to have the responsible party sign a new admission agreement for $8,000. Administrator stated R1 increased from a Level 4 to Level 5 care plan, and believed the increase was valid. Credible witness interviewed confirmed R1 had no change in care needs since moving into the facility. Another responsible party confirmed they received an increase notice on March 22, with an effective date of May 15, which was not a full 60 days’ notice. It was also alleged the licensee was charging R1 $350 per month for incontinence supplies, even though hospice was providing them. R1’s POA confirmed R1 was being charged $350 from the facility directly for incontinence supplies, even though the incontinence supplies were being provided through insurance and hospice. Responsible party stated administrator said they put the hospice incontinence supplies “in the supply closet as back up.” Interviews confirmed the briefs were all comingled in the supply closet, and staff used them for any resident. In addition, R1’s POA stated the administrator asked for the $350 to be paid in advance. After R1’s responsible party discussed the issue with the licensee in January 2024, they agreed to remove the $350 charge. However, the licensee sent a letter on 1/2/2024 indicating there was a balance owed on R1’s account and they were serving an eviction notice due to nonpayment. R1’s responsible party refused to pay the additional cost. The administrator later sent a text stating they did not need to pay the $1,000. The fact remains R1 and their responsible party were not given proper notice of the rate increase. Based on the information obtained, the allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D): Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit. to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. The licensee is reminded of their responsibility to follow admission agreements. On the allegation: Insufficient staffing to meet resident's needs. It was alleged that staff were not showing up to their shift due to the administrator not paying staff. Interviews revealed multiple staff’s hours were cut and their days of work decreased. Additionally, when staff went to pick up their paycheck it was not available. It was also stated the licensee would hold the checks in their possession and tell staff they needed to do additional work to receive the check. Other times staff had to follow the licensee to the bank, and the licensee handed them cash. Interviews revealed staff sometimes worked double shifts to cover staffing, otherwise the administrator or their partner would come in to cover the shift. Interviews revealed more staff at night would be beneficial, but there was insufficient evidence to prove any residents’ needs were not met as a result. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. The licensee is reminded of their responsibility to ensure sufficient staffing at all times. On the allegation: Facility is not kept at a comfortable temperature for residents. It was alleged residents at the facility complained of being cold. One resident’s visitor stated when they visit a resident, the resident complains about being cold. The visitor has requested numerous times that the heat be turned on. The visitor stated one resident’s hands were observed to be purple, and another resident woke up and stated it was always cold in there. Interviews revealed the bathrooms can be cold because they have no heating, so the hot water needs to be run for a while to warm up the bathroom. Some persons interviewed believe the common area can be cold for residents if the air conditioning is blowing directly on them, while others interviewed stated the temperature in the facility was comfortable. Administrator stated some residents are always cold, so they provide them blankets. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. The licensee is reminded of their responsibility to provide residents a comfortable temperature. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Apr 21, 2025 · control 29-AS-20240111092634

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Apr 25, 2025

1569.657(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative…written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section when they increased R1’s rate without justification, which posed a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2025

Plan of correction: Licensee/Administrator agrees to submit a signed statement of understanding of 1569.657 and 87507, pertaining to admission agreements and rate increases.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management - Annual Continuation visit to the above-named facility. The facility is a one-story Residential Care Facility for the Elderly (RCFE) with a capacity of fifteen (15) residents. The facility is a memory care facility for residents with a dementia diagnosis. At the time of arrival, there were three (3) staff on duty and twelve (12) residents in care. LPA met with Emily Gerr, Administrator and explained the purpose of the visit. The facility has a fire clearance for fifteen (15) non-ambulatory residents and a hospice waiver for six (6) residents. Currently, there are three (3) residents receiving hospice services. LPA observed three (3) fire extinguishers were last serviced on 3/31/2025. The facility consists of a large common area used for dining and activities. Equipment and supplies are kept in a locked cabinet located in the hallway of the facility. LPA observed a comfortable room temperature throughout the facility. LPA observed the living room and dining area to be neat and clean. Due to time restraints, LPA will continue the annual inspection at a later date.the state’s words, verbatim · CDSS document, Apr 21, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required Inspection of the facility. At the time of arrival, there were four (4) staff on duty and thirteen (13) residents in care. LPA met with Emily Gerr, Administrator and explained the purpose of the visit. Entrance interview conducted: The facility is a one-story Residential Care Facility for the Elderly (RCFE) with a capacity of fourteen (14) residents. The facility is a memory care facility for residents with a dementia diagnosis. The facility has a fire clearance for fifteen (15) non-ambulatory residents and a hospice waiver for six (6) residents. Currently, there are three (3) residents on hospice residing in the facility. LPA toured the facility with Administrators Emily Gerr. The facility consists of a large common area used for dining and activities. Equipment and supplies are kept in a locked cabinet located in the hallway of the facility. Residents participate at will in activities such as entertainment with live music, karaoke, board and card games, arts and crafts, NatureTrak, Cycling without Age, and general outings to parks, museums, and special events. LPA observed a comfortable room temperature throughout the facility. LPA observed the living room and dining area to be neat and clean. The kitchen area consists of two sinks, a dishwasher, refrigerator, freezer, stove/oven, microwave, coffee makers, toasters, fresh juice machine, mixer/blender, waffle iron and two dishwashing machines. At approximately 1:35 pm, LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined Staff 1 (S1) has worked in the facility since November 2024 and has not been properly associated to the facility prior to employment. Please continue to 809-C, Pg 2. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors, and floor coverings were checked. There are three (3) fire extinguishers on the premises last serviced on 3/28/2024. There are approximately fifteen (15) smoke alarms and one (1) carbon monoxide detector all in good working order. Due to time restraints, LPA will return at a later date to conclude the inspection. 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 at the time of the visit.the state’s words, verbatim · CDSS document, Feb 21, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management - Annual Continuation visit to the facility above. LPA met with Emily Gerr, Administrator and explained the purpose of the visit. Entrance interview conducted: The facility is a one-story Residential Care Facility for the Elderly (RCFE) with a capacity of fourteen (14) residents. The facility is a memory care facility for residents with a dementia diagnosis. The facility has a fire clearance for fourteen (14) non-ambulatory residents of which three (3) may be bedridden, and a hospice waiver for six (6) residents. Currently, there are three (3) residents receiving hospice services and no bedridden residents residing in the facility. Staff records were reviewed for health screenings, tranings, and current First Aid/CPR certification. All staff have received a criminal background clearance. At approximately 1:25 pm, LPA observed four smoke alarms located in the breakfast knook, dining area, north end of the hallway, and south end of the hallway with extremely weak or no signals. Due to time restraints, LPA will continue the annual inspection at a later date. 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 issued at the time of the visit.the state’s words, verbatim · CDSS document, Feb 16, 2024

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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required Inspection of the facility. At the time of arrival, there were five (5) staff on duty and fourteen (14) residents in care. LPA met with Emily Gerr, Administrator and explained the purpose of the visit. Entrance interview conducted: The facility is a one-story Residential Care Facility for the Elderly (RCFE) with a capacity of fourteen (14) residents. The facility is a memory care facility for residents with a dementia diagnosis. The facility has a fire clearance for fourteen (14) non-ambulatory residents of which three (3) may be bedridden, and a hospice waiver for six (6) residents. Currently, there are three (3) residents on hospice and no bedridden residents residing in the facility. LPA toured the facility with Administrators Emily Gerr and Lisa Gerr. The facility consists of a large common area used for dining and activities. Equipment and supplies are kept in a locked cabinet located in the hallway of the facility. LPA observed a comfortable room temperature throughout the facility. LPA observed the living room and dining area to be neat and clean. The kitchen area consists of two sinks, a dishwasher, refrigerator, freezer, stove/oven, microwave, coffee makers, toasters, fresh juice machine, mixer/blender, waffle iron and two dishwasher machines. At approximately 12:14 pm, LPA observed numerous plates, cups, bowls, glasses, flatware, and other miscellaneous items in a sink. LPA observed food waste, liquids, and other debris on many of the items. LPA observed four kitchen counters with a clutter-like appearance with kitchen appliances, knick-knacks, vases, and boxes of fruit. Additionally, LPA observed the kitchen counters to have dark mildew/debris between the tile pieces. At approximately 1:50 pm, LPA observed an electrical outlet with blue tape over the outlet located at the side of the bed in Room 4. LPA observed the outlet to be within close reach of a resident in care. At approximately 1:55 pm, LPA observed a washing machine and dryer stored on the west patio. LPA observed facility staff removed the equipment at approximately 3:15 pm. <Please continue to 809-C, Pg 2. At approximately 2:15 pm, LPA observed the facility business license expired as of 5/12/2023. LPA emphasized the importance of a current business license to ensure local fire marshal regulations are observed. The facility has twelve bedrooms. Each resident’s bedroom has a bed, mattress, nightstand, chair, dresser, and closet. Overhead lighting and lamps on the nightstands provide sufficient lighting in each bedroom. The hallway has night lights and ample lighting. There are three bathrooms throughout the facility. Two of the bathrooms are located off the hallway, one bathroom is located in the laundry room behind the dining area. Residents have access to each bathroom. LPA observed four fire extinguishers that were serviced on 3/29/2023. LPA observed smoke detectors and one carbon monoxide detector to be in good working order. Residents will participate in various activities based on their individual interests and preferences, including word games, card games, board games, arts and crafts, painting and drawing, outings to local parks, beaches, museums, Santa Barbara Zoo and local eateries. Exercise classes such as stretch and yoga, floor bowling, and ball toss are also offered. Visitors from community organizations assist residents in Brain Exercise Initiative (BEI) which includes trivia activities and other mentally stimulating activities. Due to time restraints, LPA will return at a later date to continue the inspection. The following deficiencies were observed (see LIC809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies by the correction due date may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.the state’s words, verbatim · CDSS document, Jan 31, 2024