Inspection Reports for
Oakmont of Montecito

The visit was complaint-related, triggered by an incident report received on 10/17/2025 regarding an altercation between two residents on 10/11/2025. The complaint was amended to unsubstantiated findings but resulted in a citation.

The licensee did not comply with personal rights regulations as one resident slapped another, posing a potential risk to health, safety, or personal rights. A deficiency was cited under CCR 87468.1(a)(1).

The complaint alleged inadequate supervision by facility staff resulting in resident altercations. The allegation was unsubstantiated as there was insufficient evidence to prove the violation occurred.

The investigation found that resident R2 slapped resident R1 in the face during an altercation on 10/11/2025. Staff intervened and police were called. No injuries were noted. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The facility was generally found to be in compliance with emergency and infection control plans, food safety, and facility maintenance. However, deficiencies were cited for 7 out of 8 staff members lacking current First Aid and CPR certification, posing an immediate risk to residents.

The visit was complaint-related, following a self-reported incident of elopement by resident R1 on 10/11/2024. The deficiency was substantiated and a civil penalty was assessed.

The facility failed to provide adequate supervision to resident R1, resulting in an elopement. No injuries occurred, but this was cited as a deficiency and a civil penalty of $500 was assessed.

The facility failed to provide adequate supervision to resident R1, resulting in an elopement. The resident was found outside the community at a neighborhood park without injuries. A deficiency was cited for this failure.

The complaint investigation was triggered by a report received on 4/15/2024 concerning abuse of residents by a staff person. The facility staff reported the abuse to management on 4/12/2024 but failed to make the required report to the agency within 24 hours, resulting in a deficiency.

The investigation revealed that facility staff failed to make timely reports of suspected physical abuse of residents by a staff person, as required by law, posing an immediate risk to resident health and safety. A deficiency was cited for failure to comply with mandated reporting requirements.

The facility was generally compliant with regulations including environment, food storage, medication storage, and staff training. However, a deficiency was found in the Memory Care unit where residents' bed sheets were wet and had an incontinence odor, posing a potential health and safety risk.

The complaint alleged staff abused a resident in care. The allegation was substantiated. Staff member S1 physically abused multiple residents over a two-week period. S1 was arrested and excluded from the facility. Facility staff failed to fulfill mandated reporting requirements.

The allegation of staff abuse was substantiated based on interviews, document review, and record review. Staff member S1 was found to have physically abused multiple residents, and the facility failed to fulfill mandated reporting requirements.

Complaint was substantiated. Allegations included failure to provide proper rate increase notice and not following terms of admission agreement. Facility was unable to prove timely notification to resident's responsible party prior to 12/8/2023.

The investigation substantiated that the facility did not provide proper written notice of rate increases within two business days as required by regulation. The facility charged an incorrect base rent rate for August and September and was unable to prove timely notification to the responsible party. Deficiencies were cited related to failure to provide proper rate increase notice.

The complaint investigation was triggered by allegations that staff failed to administer medications as prescribed and failed to ensure medications were filled. The medication administration allegation was unsubstantiated, but the failure to communicate with the resident's authorized representative was substantiated.

The investigation found that the facility ran out of medication for a resident resulting in missed doses on 10/29/2023 and 10/30/2023 due to a delay in medication refill by the Medical Clinic. The facility made reasonable attempts to obtain the medication. The allegations regarding medication administration were unsubstantiated. However, a separate allegation that staff did not communicate with the resident's authorized representative was substantiated, with evidence showing the representative was not notified timely about the medication issue, violating the resident's personal rights.

The visit was complaint-related based on an incident report of a resident found wandering outside the facility. The complaint was substantiated by the finding that staff did not respond to the auditory exit alert device.

The facility failed to respond to the auditory exit alert device, allowing a resident with dementia and exit-seeking behavior to elope. The facility has since retrained staff, placed a wanderguard alert device on the resident, increased supervision, and assigned a 1:1 companion.

The inspection was triggered by a complaint investigation (#21-AS-20230901102047). Incident reports revealed delays in reporting incidents to the licensing agency, including an incident on 9/20/23 reported on 10/4/23, which was not within the required 7 days.

The facility had multiple deficiencies including unlocked medications without physician crush orders, retention of a resident with a prohibited condition, incomplete medical assessments, failure to seek timely medical attention, inadequate staffing in memory care, failure to report incidents timely, and staff training deficiencies.

Ten complaints have been received since the licensure date of 6/9/2022, which led to substantiated findings and the implementation of the Non-Compliance plan.

The facility has ongoing issues including failure to seek timely medical attention, inadequate staffing in the memory care unit, improper handling and securing of medications resulting in errors, and incomplete resident medical assessments and care notes. These issues were identified during complaint investigations and substantiated findings.

The visit included follow-up on three incident reports of suspected financial abuse involving missing money and jewelry from residents' apartments. The facility is conducting an internal investigation with findings due by 06/30/2023. Police were notified and cases are open.

The facility was generally compliant with environmental and safety regulations, but deficiencies were noted including unsanitary conditions in a bathroom, unlocked medications previously, incomplete resident care notes, inadequate staffing in memory care, incomplete medical assessments for one resident, and failure to obtain criminal record clearance for one staff member. The facility is conducting an internal investigation regarding suspected financial abuse incidents.

Complaint investigation regarding missing personal property of former resident R1; findings substantiated with deficiencies cited.

The facility failed to produce an inventory or waiver for R1's personal property and did not follow its Theft and Loss Policies when glasses and hearing aids belonging to R1 were found missing. Deficiencies were cited under California Code of Regulations, Title 22.

The visit was complaint-related following a self-report of a medication error on 3/4/2023 and a suspected physical abuse incident on 3/31/2023. The physical abuse incident was investigated and determined to be not substantiated, but further investigation is needed. The medication error resulted in staff retraining.

The facility had residents with unlocked medications contrary to physician orders, a medication error occurred on 3/4/2023 resulting in staff retraining, retention of a resident with a prohibited condition, failure to seek timely medical attention, incomplete medical assessments, inadequate staffing in memory care, and failure to report certain incidents. An incident of suspected physical abuse on 3/31/2023 was investigated and found not substantiated but requires further review.

The facility had multiple issues including medication errors, retention of a resident with a prohibited condition, failure to seek timely medical attention, incomplete medical assessments, inadequate staffing in Memory Care, and failure to report certain incidents. An incident of suspected physical abuse was investigated but found not substantiated, with further review pending.

The complaint investigation was unannounced and addressed allegations including resident injury due to lack of care and supervision, failure to report incidents to authorized persons, and staff not meeting resident needs. One allegation was substantiated based on evidence of neglect and poor hygiene, while others were unsubstantiated due to insufficient evidence.

The investigation found one allegation unsubstantiated regarding injury due to lack of care and supervision, and one allegation substantiated regarding staff not meeting resident's needs, including neglect evidenced by poor hygiene and a broken wheelchair. The substantiated deficiency posed an immediate risk to resident health and safety.

The complaint was substantiated. Staff did not prevent a resident's television from interfering with another resident's sleep, violating personal rights. The investigation was conducted by Licensing Program Analyst Cuadra and Evaluator Jill Nakagawa.

The investigation found that staff failed to ensure the television volume of residents R2 and R3 did not interfere with resident R1's sleep, violating residents' personal rights. The allegation was substantiated based on interviews, observations, and record reviews.

The memory care unit was found clean, orderly, and adequately staffed. A medication error was identified from a prior incident report where a staff member failed to ensure the correct medication dosage was administered, posing an immediate health and safety risk.

The memory care unit was clean, orderly, and adequately staffed. A medication error incident from 11/25/2022 was reviewed, where a staff member failed to ensure the correct medication dosage was given, posing an immediate health and safety risk.

During the complaint investigation, the unsecured bottle of fingernail polish remover was observed by Licensing Program Analyst (LPA) David Leibert in the Memory Care bathroom of apartment 121. The item was removed and given to the Memory Care Director, who committed to providing additional refresher training to staff.

A deficiency was cited for failure to store disinfectants, cleaning solutions, poisons, and other hazardous items in a manner inaccessible to clients, as evidenced by the unsecured fingernail polish remover posing an immediate risk to residents' health.

The complaint was substantiated based on evidence that the resident's responsible person did not consent to the vaccination given at the facility flu shot clinic on October 27, 2022.

The investigation substantiated the allegation that the facility provided a flu shot to a resident during a facility-sponsored clinic without the consent of the resident's responsible person, posing an immediate risk to the resident's health and personal rights.

Complaint investigation was conducted for allegations including resident sustaining multiple injuries due to a fall during transfer, failure of administrator to report unusual incident, mold issues, and uncleared adults providing care. Only the injury allegation was substantiated; others were unsubstantiated due to lack of preponderance of evidence.

The allegation that a resident sustained multiple injuries due to a fall during a transfer was substantiated based on observations and record reviews. Other allegations regarding failure to report an unusual incident, mold issues, and uncleared adults providing care were found to be unsubstantiated. One deficiency was cited related to personnel requirements due to a caregiver transferring a resident alone instead of with two-person assist as required by the care plan.

The facility was found to be clean and in good repair with proper food storage and staffing. However, 4 out of 6 resident medical assessments were incomplete, specifically residents R1-R4 had not submitted signed physician reports, posing a potential health and safety risk.

The complaint investigation was substantiated. Allegations included failure to follow resident's care plan, failure to respond to resident's alarm, and failure to dispense medication as prescribed. The investigation found sufficient evidence to support these allegations based on observations, interviews, and documentation review.

The investigation substantiated that the facility failed to follow the resident's care plan, did not respond to the resident's alarm, and did not dispense medication as prescribed. Specific deficiencies included failure to assist with breathing treatments as ordered, failure to respond to sensor alarms leading to a resident wandering and falling, and failure to follow care plan and doctor's orders. Other allegations regarding hygiene assistance, bathroom sanitation, and admission agreement were unsubstantiated. Two Type B deficiencies were cited related to personnel requirements and personal rights, and one deficiency was dismissed.

Visit was complaint-related due to an incident report of resident R1 eloping. The deficiency was substantiated as the facility failed to implement adequate safety measures for dementia residents.

The facility failed to meet safety measures to address wandering behaviors for resident R1, who eloped without staff knowledge, posing an immediate health and safety risk. The facility conducted staff training, reviewed elopement policies, and scheduled an elopement drill as corrective actions.