Inspection Reports for
Westmont of Santa Barbara
190 Via Jero, Goleta, CA 93117, USA, CA, 93117
Back to Facility ProfileCitations (last 5 years)
Citations (over 5 years)
7.2 citations/year
Citations are regulatory findings recorded during state inspections.
80% worse than California average
California average: 4 citations/year
Citations per year
16
12
8
4
0
Occupancy
Latest occupancy rate
73% occupied
Based on a January 2026 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Capacity: 99
Citations: 5
Date: Jan 27, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2025-06-04 regarding staff leaving residents unattended, failure to respond to requests for assistance, unsanitary resident rooms, lack of activities, failure to ensure residents receive their mail, and unsanitary bedding.
Complaint Details
The complaint investigation was substantiated. Allegations included staff leaving residents unattended for extended periods, failure to respond to requests for assistance, odiferous resident rooms, lack of activities, failure to ensure residents receive mail, and unsanitary bedding. Multiple interviews, record reviews, and observations supported these findings.
Findings
The investigation substantiated all allegations including prolonged wait times for staff response to call buttons, unsanitary conditions and odors in resident rooms, lack of activities due to staffing shortages, failure to safeguard residents' mail packages, and inadequate cleaning and changing of residents' bedding. The facility was found to be short staffed at times, impacting timely care and housekeeping services.
Citations (5)
Residents that pushed call buttons for care needs waited prolonged periods of time for assistance, posing potential health, safety and personal rights risks.
Incontinent residents were not kept clean and dry and the facility was not free of odors from incontinence.
One staff member did not have full-time responsibility to organize, conduct and evaluate planned activities, resulting in activities not being conducted as scheduled.
Failure to protect residents' property from theft or loss; packages delivered to the facility were not properly logged or safeguarded.
Clean linen was not changed at least once per week or more often when indicated, resulting in residents not having clean linen at all times.
Report Facts
Capacity: 99
Call button wait times: 96
Number of residents reviewed for call button logs: 7
Number of substantiated allegations: 6
Plan of Correction Due Dates: Feb 3, 2026
Plan of Correction Due Date: Mar 3, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jade Alma-Harris | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Rachael De Leon | Licensing Program Analyst | Conducted complaint investigation and authored report |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 99
Citations: 1
Date: Jan 27, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including insufficient staffing to respond to residents' calls, inadequate dining room staffing, lack of activities staff, insufficient housekeeping services, and poor communication by the Licensee/Administrator.
Complaint Details
The complaint investigation was substantiated. Allegations included untimely response to residents' calls for assistance, insufficient dining room staffing, lack of activities staff for several months, inadequate housekeeping services, and poor communication by the Licensee/Administrator. Multiple interviews, record reviews, and observations confirmed these issues.
Findings
The investigation substantiated all allegations, finding that residents experienced long wait times for assistance, insufficient dining room staffing causing meal delays, activities were cancelled or inadequately provided due to staff shortages, housekeeping services were not performed weekly leading to unsanitary conditions, and communication with residents and responsible parties was poor due to staff turnover.
Citations (1)
Residents in all residential care facilities for the elderly shall have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met due to staff turnover and lack of communication from Administrator/Licensee.
Report Facts
Residents with call button logs over 15 minutes: 3
Capacity: 99
Census: 72
Plan of Correction Due Date: Feb 3, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jade Alma-Harris | Administrator | Met with Licensing Program Analyst during investigation and named in findings related to communication deficiencies. |
| Rachael De Leon | Licensing Program Analyst | Conducted the complaint investigation visits and interviews. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 99
Citations: 0
Date: Sep 10, 2025
Visit Reason
An unannounced case management incident visit was conducted regarding a self-reported incident and a self-reported death of a resident that occurred on 2025-08-31.
Complaint Details
The visit was triggered by a complaint related to a resident's increased confusion and subsequent death. The death cause was unknown at the time of the report, and the circumstances were considered questionable, requiring investigation.
Findings
The investigation involved review of incident and death reports and in-person interviews. No deficiencies were noted during the visit, and the Licensing Program Analyst will return to continue the investigation due to time constraints.
Report Facts
Incident date: Aug 31, 2025
Time of incident: 1515
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the unannounced case management incident visit and investigation |
| Jade Alma-Harris | Administrator | Facility administrator met with Licensing Program Analyst during the visit |
Inspection Report
Census: 65
Capacity: 99
Citations: 1
Date: Sep 10, 2025
Visit Reason
A Case Management visit was conducted to address deficiencies noted during a Case Management – Incident visit on the same day.
Findings
A confidential document pertaining to one resident was found in another resident's file, which is a violation of confidentiality regulations and poses a potential safety and personal rights risk to residents in care.
Citations (1)
Failure to maintain confidentiality of resident records as a confidential document of one resident was found in another resident's record.
Report Facts
Capacity: 99
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jade Alma | Administrator | Met with during the inspection and involved in the confidentiality finding |
| Kristin Kontilis | Licensing Program Analyst | Conducted the Case Management visit |
| Kelly Burley | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 64
Capacity: 99
Citations: 1
Date: Aug 26, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements at the Residential Care Facility for the Elderly.
Findings
The facility was generally found to be in good repair and clean. However, a significant medication error was identified where a resident was administered Hydromorphone twice within 10 minutes by two different staff members, posing an immediate health and safety risk.
Citations (1)
Resident was administered Hydromorphone 2mg twice within 10 minutes by two different staff members, violating medication administration protocols.
Report Facts
Residents in care: 48
Residents in care: 16
Residents on hospice: 11
Fire extinguishers: 14
Fire pull alarms: 5
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jade Alma-Harris | Administrator | Present during inspection and involved in medication error investigation |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection |
| Kelly Burley | Licensing Program Manager | Named in report as licensing program manager |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 99
Citations: 0
Date: Aug 13, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations regarding staff communication with authorized representatives, resident reassessment, and proper feeding of a resident.
Complaint Details
The complaint included allegations that staff do not communicate effectively with authorized representatives, do not properly reassess a resident while in care, and do not ensure a resident is being properly fed. The investigation found these allegations unsubstantiated based on interviews, documentation, and observations.
Findings
The investigation found no evidence to support the allegations. Staff were found to communicate effectively with authorized representatives, resident reassessments were scheduled despite delays due to administrative transition, and the resident's feeding and weight management were within acceptable standards. All allegations were unsubstantiated.
Report Facts
Facility capacity: 99
Census: 74
Complaint received date: May 30, 2025
Weight monitoring standards: 5
Weight monitoring standards: 7.5
Weight monitoring standards: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Jeffries | Licensing Program Analyst | Conducted the complaint investigation and issued findings |
| Jade Alma-Harris | Facility Administrator | Interviewed regarding communication with resident's family |
| Carolina Nava | Business Office Director | Met with Licensing Program Analyst during investigation |
| Kelly Burley | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Follow-Up
Census: 68
Capacity: 99
Citations: 1
Date: Nov 8, 2024
Visit Reason
A Case Management visit was conducted to address deficiencies noted during a prior complaint investigation visit on 11/08/2024.
Complaint Details
The visit was a follow-up to deficiencies noted during Complaint Control #29-AS-20241104104759 investigation visit conducted on 11/08/2024.
Findings
The facility was found to have a stained and soiled carpet in a resident's room, which poses a potential health, safety, or personal rights risk. The administrator acknowledged that five residents' rooms require carpet cleaning service.
Citations (1)
The carpet in a resident's room was observed to be stained and soiled, posing a potential health, safety, or personal rights risk.
Report Facts
Deficiency Plan of Correction Due Date: Nov 15, 2024
Census: 68
Total Capacity: 99
Number of rooms needing carpet cleaning: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the Case Management visit and licensing evaluation |
| Ernest Lewis | Executive Director | Facility administrator met during the inspection and provided information about carpet cleaning needs |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 68
Capacity: 99
Citations: 6
Date: Jul 25, 2024
Visit Reason
The visit was a Case Management - Annual Continuation inspection to review compliance with licensing requirements, including medication inventory, resident records, and facility conditions.
Findings
The inspection revealed multiple deficiencies including medication errors, incomplete medication records, lack of required staff training, missing pre-admission appraisals, unclean patio areas, and failure to submit required administrator paperwork. Plans of correction were agreed upon with due dates in late July 2024.
Citations (6)
Staff trainings did not include a minimum of four hours per year of training in postural support, restricted health conditions, and hospice care.
A Pre-Admission Appraisal was not conducted for Resident 10 prior to admission.
Residents did not receive their medication as prescribed, posing an immediate health and safety risk.
Resident 1’s Centrally Stored Medication Record did not list two prescribed medications.
Outside patio areas between Assisted Living and Memory Care were unclean and unsanitary due to birds nesting.
Licensee failed to notify the Department in writing within 30 days of hiring a new administrator and did not submit required paperwork naming the current Acting Executive Director as administrator.
Report Facts
Census: 68
Total Capacity: 99
Plan of Correction Due Date: Jul 27, 2024
Plan of Correction Due Date: Jul 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernest Lewis | Acting Executive Director | Met during inspection and named in plans of correction and findings |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection |
| Mark Cortes | Administrator/Director | Named as facility administrator, though no current paperwork submitted |
Inspection Report
Annual Inspection
Census: 68
Capacity: 99
Citations: 0
Date: Jul 24, 2024
Visit Reason
Licensing Program Analyst Kristin Kontilis conducted a Case Management - Annual Continuation visit to review residents' records and compliance with health screenings, medication administration, and other regulatory requirements.
Findings
No deficiencies were noted during the inspection. The Licensing Program Analyst reviewed multiple resident records and conducted entrance and exit interviews.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the Case Management - Annual Continuation visit. |
| Ernest Lewis | Interim Administrator | Met with Licensing Program Analyst during the inspection. |
Inspection Report
Annual Inspection
Census: 68
Capacity: 99
Citations: 0
Date: Jul 23, 2024
Visit Reason
The inspection was an unannounced required annual inspection of the Residential Care Facility for the Elderly (RCFE) to evaluate compliance and facility conditions.
Findings
The facility was found to be in good repair with no deficiencies noted. The physical environment, kitchen, and safety equipment were all satisfactory. Residents participate in various activities, and the facility maintains a comfortable and safe environment.
Report Facts
Residents in Assisted Living unit: 41
Residents in Memory Care unit: 27
Fire extinguishers: 18
Fire pull alarms: 5
Dual carbon monoxide detectors and smoke alarms: 81
Non-ambulatory residents: 99
Bedridden residents: 10
Residents on hospice: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernest Lewis | Interim Administrator | Present at time of inspection and met with Licensing Program Analyst |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection |
| Kelly Burley | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 99
Citations: 1
Date: Jul 12, 2024
Visit Reason
An unannounced case management visit was conducted to issue additional deficiencies discovered while investigating complaints at the facility, specifically regarding medication administration to Resident 1.
Complaint Details
The investigation was triggered by complaint 29-AS-20240515122500 alleging that Resident 1 did not receive their prescribed eyedrops. The complaint was substantiated by review of Medication Administration Records and staff interviews.
Findings
The facility failed to notify Resident 1's physician of multiple instances where prescribed eyedrops were not administered due to the resident being asleep, posing an immediate health and safety risk. Only two refusals were documented as communicated to the physician, which did not meet regulatory requirements.
Citations (1)
Observation of the Resident. When changes are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and responsible person. This requirement was not met as evidenced by failure to notify physician of missed medications.
Report Facts
Census: 67
Total Capacity: 99
Plan of Correction Due Date: Jul 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Ernest Lewis | Interim Administrator | Met with Licensing Program Analyst during inspection |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 99
Citations: 2
Date: Jul 2, 2024
Visit Reason
An unannounced case management visit was conducted to issue additional deficiencies discovered while investigating complaints and reviewing incident reports related to medication errors and failure to report a bus accident involving residents.
Complaint Details
The visit was complaint-related due to medication errors reported by the interim Administrator and failure to report a bus accident involving residents. The medication errors involved 21 residents not receiving their morning medications on 5/27/2024. The bus accident occurred on 3/8/2024 with three residents on board and was not reported as required.
Findings
The facility failed to provide morning medications to 21 residents on 5/27/2024 due to staff being overwhelmed, and only 10 of these incidents were reported to the licensing agency. Additionally, the facility failed to report a bus accident involving residents that occurred on 3/8/2024. Deficiencies were cited for failure to provide medication as prescribed and failure to report incidents as required.
Citations (2)
Failure to provide medication as prescribed to multiple residents, posing an immediate health and safety risk.
Failure to report a bus accident involving residents and medication errors to the licensing agency, posing a potential health and safety risk.
Report Facts
Residents not receiving medication: 21
Incident reports received: 10
Facility capacity: 99
Census: 71
Plan of Correction due date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Mark Cortes | Administrator/Director | Facility Administrator named in the report header |
| Jessica Zebroski | Resident Services Director Specialist | Met with Licensing Program Analyst during the visit |
| Ernest Lewis | Acting Executive Director | Interviewed during investigation and agreed to corrective actions |
| Sheryl McCaskill | Interim Administrator | Reported medication errors and discussed bus accident reporting |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 99
Citations: 3
Date: Jun 17, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2022-11-21 regarding multiple allegations including insufficient staffing, inadequate response to call buttons, lack of training, and disrespectful treatment of residents.
Complaint Details
The complaint investigation was substantiated for allegations including insufficient staffing, delayed response to call buttons, inadequate staff training, and disrespectful treatment of residents. Other allegations such as medication mismanagement, mishandling of residents, facility disrepair, COVID-19 guideline violations, unkempt conditions, and failure to communicate with responsible parties were unsubstantiated.
Findings
The investigation substantiated allegations of insufficient staffing, delayed response to call buttons, inadequate staff training, and disrespectful treatment of residents. Several other allegations including medication mismanagement, mishandling of residents, facility disrepair, COVID-19 guideline violations, unkempt conditions, and failure to communicate with responsible parties were found unsubstantiated.
Citations (3)
Facility personnel were not sufficient in numbers, particularly dining staff, which posed a potential health and safety risk to residents.
Staff did not answer call buttons timely, posing a potential health and safety risk to residents.
Staff did not have adequate training in 2022, posing a potential health and safety risk to residents.
Report Facts
Capacity: 99
Census: 69
Call button response times: 295
Call delays: 19
Call delays: 12
Call delays: 3
Call delays: 4
Call delays: 3
Call delays: 3
Call delays: 1
Call delays: 1
Call delays: 1
Staff training hours: 6
Staff training hours: 5.25
Staff training hours: 4.75
Staff training hours: 25.5
Staff training hours: 16.5
Plan of Correction Due Date: Jun 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation and issued final findings |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation report |
| Sheryl McCaskill | Interim Administrator | Met with Licensing Program Analyst during investigation and referenced in findings |
| Mark Cortes | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Capacity: 99
Citations: 2
Date: Jun 13, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-10-20 regarding staff response to resident requests and reporting incidents to responsible parties.
Complaint Details
The complaint alleged staff did not respond to a resident's request for assistance and failed to report an incident to the resident's responsible party. The allegations were substantiated based on interviews, call button logs, and record reviews.
Findings
The investigation substantiated that staff failed to respond promptly to Resident 1's call button for assistance, resulting in a 35-minute delay that posed an immediate health and safety risk. Additionally, the facility did not notify Resident 1's responsible party in writing about the incident as required, posing a potential health, safety, and personal rights risk.
Citations (2)
Failure to respond to Resident 1's call button for assistance, posing an immediate health and safety risk.
Failure to notify Resident 1's responsible party in writing of the incident within seven days, posing a potential health, safety, and personal rights risk.
Report Facts
Call button response time: 35
Capacity: 99
Deficiency Type A POC Due Date: Jun 14, 2024
Deficiency Type B POC Due Date: Jun 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation and issued final findings. |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation report. |
| Mark Cortes | Administrator | Facility administrator named in the report. |
| Sheryl McCaskill | Interim Administrator | Met with Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 99
Citations: 1
Date: Jun 13, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations including staff speaking inappropriately to residents, failure to seek timely medical attention for a resident, and serving non-nutritious meals.
Complaint Details
The complaint investigation was substantiated for the allegation that staff spoke inappropriately to residents. The allegations regarding failure to seek timely medical attention and serving non-nutritious meals were unsubstantiated.
Findings
The allegation that staff spoke inappropriately to residents was substantiated, with evidence of disrespectful communication and a cited deficiency related to personal rights. The allegation that staff did not seek timely medical attention for a resident was unsubstantiated based on documentation and interviews. The allegation that the facility served non-nutritious meals was also unsubstantiated, though residents expressed dissatisfaction with food quality and nutritional balance.
Citations (1)
Failure to accord dignity in personal relationships with staff, residents, and others as staff spoke inappropriately to residents, posing a potential personal rights risk.
Report Facts
Facility capacity: 99
Census: 69
Deficiency count: 1
Plan of Correction due date: Jun 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation and issued final findings |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation and signed report |
| Sheryl McCaskill | Interim Administrator | Met with Licensing Program Analyst during investigation |
| Mark Cortes | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 62
Capacity: 99
Citations: 1
Date: Sep 13, 2023
Visit Reason
The visit was a Case Management - Annual Continuation inspection conducted to review staff records, resident medication administration, and compliance with regulations.
Findings
The inspection revealed that two staff members did not have required intradermal tests and/or chest x-rays upon hire, and medication administration errors were found with 11 errors out of 24 medications reviewed.
Citations (1)
Licensee did not comply with medication administration per physician's orders; 7 out of 24 medications were not administered as ordered, posing immediate health and safety risks.
Report Facts
Medication errors: 11
Medications not administered per orders: 7
Census: 62
Total capacity: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Cortes | Administrator | Met with Licensing Program Analyst during inspection |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kelly Burley | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Annual Inspection
Census: 62
Capacity: 99
Citations: 0
Date: Sep 8, 2023
Visit Reason
The visit was a Case Management - Annual Continuation inspection to review residents' records and ensure compliance with licensing requirements.
Findings
The Licensing Program Analyst reviewed residents' emergency contact information, admission agreements, appraisals, needs and services, and residents' rights. Due to time restraints, the inspection was to be continued at a later date.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Cortes | Administrator | Met with Licensing Program Analyst during the inspection visit. |
| Kristin Kontilis | Licensing Program Analyst | Conducted the Case Management - Annual Continuation visit. |
| Kelly Burley | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 61
Capacity: 99
Citations: 0
Date: Aug 9, 2023
Visit Reason
An unannounced required Annual Inspection was conducted to evaluate the facility's compliance with regulations as a Residential Care Facility for the Elderly (RCFE).
Findings
The facility was found to be in good repair with a clean physical environment, adequate staffing, and appropriate safety measures including fire extinguishers and smoke alarms. Activities for residents were ongoing and the kitchen and medication storage areas were clean and secure.
Report Facts
Fire extinguishers: 12
Fire pull alarms: 5
Dual carbon monoxide detectors and smoke alarms: 81
Residents in Assisted Living unit: 41
Residents in Memory Care unit: 20
Residents on hospice: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Cortes | Administrator | Present at time of inspection and involved in entrance interview |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 99
Citations: 0
Date: Aug 2, 2023
Visit Reason
Unannounced complaint investigation visit conducted to address allegations that staff yell at residents and do not provide adequate food service.
Complaint Details
Complaint investigation was unannounced and conducted following a complaint received on 07/28/2023. Allegations included staff yelling at residents and inadequate food service. The complaint was found unsubstantiated.
Findings
The investigation found the allegation that staff yelled at residents to be unsubstantiated based on interviews and observations. The allegation that staff did not provide adequate food service was also unsubstantiated, with residents generally satisfied with the food and no evidence of overly spicy meals.
Report Facts
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Cortes | Administrator | Met during investigation and provided statements regarding staff conduct and complaint handling |
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 99
Citations: 1
Date: Jul 18, 2023
Visit Reason
The visit was a Case Management visit conducted to address deficiencies noted during a complaint investigation (Complaint Control #29-AS-20230711113736) conducted on the same date.
Complaint Details
The visit was triggered by a complaint investigation (Complaint Control #29-AS-20230711113736) conducted on 07/18/2023. The deficiency related to confidentiality of resident records was substantiated.
Findings
The inspection found that the Resident Service Director's office door was fully open with residents' binders visible from the hallway, exposing confidential resident records and posing an immediate health and safety risk. The Resident Service Director acknowledged the door should be closed and locked when not in the office.
Citations (1)
Resident records were exposed when the Resident Service Director office door was fully open, violating confidentiality requirements and posing an immediate health and safety risk to residents.
Report Facts
Census: 45
Total Capacity: 99
Plan of Correction Due Date: Jul 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Cortes | Administrator | Met with Licensing Program Analyst during the visit |
| Kristin Kontilis | Licensing Program Analyst | Conducted the Case Management visit and authored the report |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Follow-Up
Census: 57
Capacity: 99
Citations: 1
Date: May 17, 2023
Visit Reason
The visit was a Case Management follow-up to address deficiencies noted during a complaint investigation conducted on 05/17/2023.
Complaint Details
The visit was conducted to address deficiencies noted during Complaint Control #29-AS-20230512135542 investigation.
Findings
The facility was found to have a deficiency related to a staff member who returned to work without being re-associated to the facility prior to working, posing an immediate health and safety risk. Civil penalties were assessed.
Citations (1)
Failure to request a transfer of a criminal record clearance prior to staff member working in the facility, posing an immediate health and safety risk.
Report Facts
Civil Penalty Amount: 3000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Cortes | Administrator | Met with Licensing Program Analyst during the visit. |
| Kristin Kontilis | Licensing Program Analyst | Conducted the Case Management visit and authored the report. |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the licensing program. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 99
Citations: 0
Date: Apr 12, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility did not have an adequate emergency disaster plan for residents requiring use of the elevator during a power outage.
Complaint Details
The complaint alleged that during a power outage on 3/22/2023, the elevator was not operational and residents, including those in wheelchairs and walkers, were told to stay in their rooms. The investigation found the facility has adequate emergency plans and training to assist residents during elevator failure and power outages. The complaint was unsubstantiated.
Findings
The investigation found that the facility has an emergency generator and documented procedures to assist residents during power outages, including the use of stair chairs and two-person carry for non-ambulatory residents. Staff have been trained on these procedures, and residents reported no issues. The allegation was deemed unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 99
Census: 57
Complaint Control Number: 29-AS-20230322155008
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Phillips | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Mark Cortes | Executive Director | Facility representative met during the investigation |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Follow-Up
Census: 68
Capacity: 99
Citations: 1
Date: Dec 20, 2022
Visit Reason
The visit was a Case Management follow-up to address deficiencies noted during a prior complaint investigation visit conducted on 12/20/2022.
Complaint Details
The visit was conducted to address deficiencies noted during Complaint Control #29-AS-20221215114140 investigation.
Findings
The Licensing Program Analyst observed multiple staff members not properly wearing face coverings, which posed an immediate health, safety, and personal rights risk to residents. Staff were reminded to wear face coverings properly at all times in the facility.
Citations (1)
Licensee failed to ensure all staff wore face coverings properly at all times while in the facility, posing an immediate health, safety, and personal rights risk to residents.
Report Facts
Capacity: 99
Census: 68
Deficiencies cited: 1
Plan of Correction Due Date: Dec 22, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Cortes | Administrator | Met with Licensing Program Analyst during the visit. |
| Kristin Kontilis | Licensing Program Analyst | Conducted the Case Management visit and cited deficiencies. |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the licensing evaluation. |
Inspection Report
Follow-Up
Census: 77
Capacity: 99
Citations: 1
Date: Nov 30, 2022
Visit Reason
The visit was a Case Management visit to address deficiencies noted during a prior complaint investigation conducted on 11/30/2022.
Complaint Details
The visit was related to deficiencies noted during Complaint Control #29-AS-20221121125215 investigation visit conducted on 11/30/2022.
Findings
The licensee did not comply with criminal record clearance requirements as 18 home care agency staff, 3 nursing consultants, and 1 corporate regional director were present and/or working in the facility without being properly associated, posing an immediate health and safety risk to residents.
Citations (1)
Failure to request a transfer of a criminal record clearance for individuals prior to working, residing, or volunteering in the facility.
Report Facts
Home care agency staff not associated prior to working: 18
Nursing consultants not associated prior to working: 3
Corporate regional director not associated prior to working: 1
Facility capacity: 99
Facility census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Cortes | Administrator | Met with Licensing Program Analyst during the visit |
| Kristin Kontilis | Licensing Program Analyst | Conducted the Case Management visit and authored the report |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 99
Citations: 1
Date: Aug 4, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-01-07 regarding maintenance issues with a resident's door and timely meal service.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility did not repair Resident 1's door, which was malfunctioning and required multiple maintenance interventions over two weeks. The allegation that the facility did not serve meals timely to the resident was unsubstantiated.
Findings
The investigation substantiated that the facility failed to ensure that Resident 1's door was functioning properly, posing a potential health and safety risk. The facility was found to have maintenance issues with the door over about two weeks. Another allegation regarding untimely meal service to the resident was found to be unsubstantiated after interviews and review of the facility's tray service adjustments.
Citations (1)
The facility failed to ensure that Resident 1's door was functioning, which posed a potential health and safety risk to persons in care.
Report Facts
Capacity: 99
Census: 80
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peter John Bonilla | Administrator | Named in relation to findings and interviews during the complaint investigation |
| Jeannette Olson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 80
Capacity: 99
Citations: 1
Date: Aug 4, 2022
Visit Reason
An unannounced one-year Infection Control Inspection visit was conducted as a required annual inspection of the Residential Care Facility for the Elderly (RCFE).
Findings
The facility was found to be in good repair and clean, with proper infection control measures in place including PPE supplies, staff training, and COVID-19 protocols. However, deficiencies were cited related to criminal record clearance for staff, with eight staff not associated to the facility and one staff lacking fingerprint clearance, posing an immediate health and safety risk.
Citations (1)
Eight facility staff were not associated to work in the facility and one staff did not receive a fingerprint clearance and/or background check prior to working, posing an immediate health and safety risk to residents.
Report Facts
Civil Penalty: 4750
Residents on Hospice: 18
Fire Extinguishers: 10
Fire Pull Alarms: 5
Dual Carbon Monoxide Detectors and Smoke Alarms: 81
Staff without prior association: 8
Staff without fingerprint clearance: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peter John Bonilla | Administrator | Present at time of inspection and involved in facility oversight. |
| Mark Cortes | Interim Administrator | Present at time of inspection and involved in facility oversight. |
| Jeannette Olson | Licensing Program Analyst | Conducted the inspection visit. |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection visit and signed the report. |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 99
Citations: 3
Date: Mar 30, 2022
Visit Reason
The visit was conducted as a Case Management - Deficiencies inspection in conjunction with a complaint investigation (Complaint Control #29-AS-20210830163115) to issue a citation for deficiencies observed during the complaint investigation.
Complaint Details
The visit was triggered by complaint #29-AS-20210830163115. The complaint investigation substantiated deficiencies related to failure to update service plans, failure to submit required incident reports, and false claims by facility staff.
Findings
The investigation found that R1's Service Plan was not updated after multiple falls requiring hospitalization, and no Unusual Incident Reports were submitted for the falls on 08/07/2021 and 08/16/2021. Additionally, the Facility Resident Services Director falsely claimed to have faxed an incident report while not present at the facility on the stated dates.
Citations (3)
R1’s Service Plan dated 07/24/2021 was not updated after multiple falls requiring hospitalization, posing an immediate health and safety risk.
Facility Resident Services Director made false claims regarding faxing incident reports, despite not being present at the facility on the dates claimed.
Failure to submit Unusual Incident Reports for R1’s falls on 08/07/2021 and 08/16/2021 which required hospitalization, posing a potential health and safety risk.
Report Facts
Census: 90
Total Capacity: 99
Deficiency Type A: 2
Deficiency Type B: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denay Ramirez | Business Administrator | Met with Licensing Program Analyst during inspection |
| Peter John Bonilla | Administrator | Facility Administrator named in report header |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection |
| Toan Luong | Licensing Program Analyst | Conducted the Case Management - Deficiencies visit |
| Santana | Investigator who observed deficiencies during complaint investigation | |
| Facility Resident Services Director | Named in findings related to false claims and incident report submission |
Inspection Report
Annual Inspection
Census: 90
Capacity: 99
Citations: 2
Date: Feb 15, 2022
Visit Reason
An unannounced One Year Infection Control Annual visit was conducted to evaluate compliance with infection control and staff criminal record clearance requirements.
Findings
The facility had not completed N95 fit testing for staff, but all other infection control items were satisfactory. However, three individuals were found working without a California Criminal Record clearance, and four cleared individuals were not listed on the Personnel Roster, resulting in citations and an immediate civil penalty.
Citations (2)
Three individuals working at the facility without a California Criminal Record clearance.
Four cleared individuals were not listed on the Personnel Roster but were listed on the staff schedule.
Report Facts
Deficiency counts: 3
Deficiency counts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peter John Bonilla | Administrator | Met with Licensing Program Analyst during inspection and involved in addressing deficiencies |
| Toan Luong | Licensing Program Analyst | Conducted the inspection and issued citations |
| Kelly Burley | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
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