Inspection Reports for
Garden Court at Villa Santa Barbara

The Licensing Program Analyst conducted a case management incident visit regarding a death report dated 03/22/2026. The resident did not have a Do Not Resuscitate (DNR) order, and the administrator was requested to provide the death certificate, cause of death, and recent medical appointments.

The complaint alleged that the facility was not maintained in a sanitary condition, specifically citing photos of a metal tray with possible mold and a yellow leaf. The allegation was found to be unsubstantiated after investigation.

The Licensing Program Analyst toured the facility and found no observable mold. Staff and resident interviews confirmed the cleanliness of the facility and the trays in question were found clean. Based on all interviews and documents obtained, the allegation was found to be unsubstantiated.

The Licensing Program Analyst conducted a cursory tour of the three-story facility noting features such as carbon monoxide detectors and a recently tested sprinkler system. The annual inspection was not completed and may be resumed at a later time.

The complaint investigation addressed multiple allegations including inappropriate staff behavior in presence of residents, failure to provide a healthy and safe environment, withholding food from residents, failure to accommodate resident food needs, and denial of resident visitors. All allegations were found unsubstantiated based on interviews, document reviews, and observations.

All allegations investigated were found to be unsubstantiated. No inappropriate staff behavior in presence of residents was observed, the facility was found to provide a healthy and safe environment, residents were not withheld food and dining services were accommodating, special dietary needs were addressed within physician orders, and resident visitation rights were respected.

Complaint alleged staff failed to answer Resident 1's call button in a timely manner, leading to a fall and serious injury including a fracture. The complaint investigation found staff did not respond to the call, resulting in the resident being unattended for hours and sustaining injuries.

The investigation revealed that staff did not respond to Resident 1's call for assistance, resulting in the resident falling and sustaining a facial laceration, hematoma, and wrist fracture. The licensee representatives discussed corrective strategies including enhanced monitoring, staff training, and system oversight. A potential civil penalty of $10,000 for serious bodily injury is under review.

The complaint investigation was unsubstantiated. Allegations included failure to assist with incontinence, facility odor issues, and a pressure injury. Investigations included interviews with staff, residents, visitors, hospice personnel, and review of documentation. The pressure injury was identified as moisture-associated skin damage, not a pressure ulcer.

After multiple visits, interviews, and document reviews, the allegations were found to be unsubstantiated due to insufficient evidence. Staff were found to be responsive to residents' needs, no foul odors were confirmed, and the alleged pressure injury was determined to be moisture-associated skin damage that had healed.

The complaint alleged that facility staff did not meet Resident 1's needs, including concerns about pressure injuries. The investigation included interviews, document reviews, and observations. The allegation was unsubstantiated due to lack of evidence of pressure injuries or wounds in hospital and hospice records.

The investigation found insufficient evidence to substantiate the allegation that facility staff failed to meet R1's needs. Medical and hospice records did not confirm any pressure injuries or wounds, and staff provided appropriate care. The allegation was deemed unsubstantiated.

The Administrator confirmed that Staff #1 has not worked at the facility since 4/22/2018 and that the staff member was not observed at the facility during the visit. No citations were issued during the visit.

The complaint alleged that staff refused to allow a resident to remove their personal belongings. The investigation included interviews and document reviews, concluding the allegation was unsubstantiated.

The investigation found that the allegation was unsubstantiated. The Administrator and Wellness Director confirmed that the resident was responsible for themselves with no POA or Responsible Party on file, and after communication with the resident's family, the resident's belongings were eventually removed from the facility.

The complaint involved allegations that staff spoke rudely and inappropriately to residents, with a specific staff member (S1) accused of using a yelling tone. The investigation included interviews with residents and staff, and the allegations were determined to be unsubstantiated.

After interviewing residents, staff, and administrators, the allegations were found to be unsubstantiated. Multiple residents reported no inappropriate staff behavior, and the administrator had conducted in-service training to remind staff of residents' rights and expectations.

The facility was found to be in good repair, clean, and compliant with licensing requirements per Title 22 California Code of Regulations. Fire safety and personal accommodations were inspected with no deficiencies noted.