Inspection Reports for
Oak Cottage of Santa Barbara

The complaint investigation was substantiated for the allegation that staff violated residents' personal rights by restricting residents' movement. The allegations that staff failed to meet resident R1's needs and failed to safeguard residents' personal belongings were unsubstantiated.

The investigation substantiated that two residents were restricted from freely moving about the facility, posing an immediate health, safety, and personal rights risk. However, allegations regarding failure to meet resident R1's bathing, grooming, and feeding needs, as well as failure to safeguard residents' personal belongings, were unsubstantiated due to insufficient evidence.

The visit was triggered by a self-reported incident. The investigation is ongoing, with no deficiencies noted so far.

During the visit, documents related to the incident were reviewed, video footage was examined, and an interview was conducted with the Administrator. No deficiencies were noted at the time of this visit, but the investigation will continue at a later date due to time constraints.

The visit was triggered by a complaint related to a resident's death following multiple falls, with failure to report incidents as required.

The facility failed to report several fall incidents involving Resident 1, including a fall on 2025-06-25, posing immediate health and safety risks. The resident had multiple falls and subsequently died in the hospital.

The inspection found the facility environment clean and well-maintained with all required safety equipment in place. Residents participate in various activities and receive assistance with daily living needs. No deficiencies were cited during the inspection.

The complaint investigation was substantiated. Allegations included inadequate supervision of residents, illegal eviction without written notice, and failure to properly report abuse. The facility failed to provide adequate supervision to a resident with aggressive behaviors, issued a verbal eviction without written notice to the responsible party, and delayed abuse reporting beyond the 24-hour requirement.

The investigation substantiated all allegations: inadequate supervision leading to resident-on-resident abuse, verbal eviction without written notice, and failure to timely report abuse incidents to the appropriate agencies.

The visit was complaint-related, triggered by incident reports of medication errors and issues with private caregivers. The medication errors were substantiated, and deficiencies were cited accordingly.

The investigation found multiple medication administration errors affecting twelve residents, failure to report a medication error timely, and thirteen private or temporary caregivers not properly associated with the facility, posing immediate health and safety risks. Deficiencies were cited under California Code of Regulations Title 22, and civil penalties were assessed.

The facility was found to be in good repair with no deficiencies cited during the inspection. The physical environment, fire safety, food service, and resident accommodations were all satisfactory. Residents participate in various activities and receive assistance with daily living needs.

The complaint investigation was substantiated regarding inadequate supervision leading to a resident elopement and injury. The allegation regarding failure to address a resident's change in medical condition was unsubstantiated.

The allegation that staff did not provide adequate supervision was substantiated, as a resident with dementia eloped from the facility resulting in injury and a $500 civil penalty was assessed. The allegation that staff did not address a resident's change in medical condition was unsubstantiated, as the facility updated the resident's service plan and scheduled a meeting with the responsible party.

The complaint investigation was substantiated for allegations of inadequate diapering and medication mismanagement. Other allegations including failure to prevent inappropriate behavior, lack of encouragement in group activities, failure to notify responsible party of change of condition, denial of visitation, and abandonment were unsubstantiated.

The investigation substantiated two allegations: staff did not meet resident's diapering needs by double diapering residents, and staff did not adequately manage resident's medication by giving PRN medications pre-emptively against physician orders. Other allegations including failure to prevent inappropriate behavior, lack of encouragement for group activities, failure to notify of change of condition, denial of visitation, and abandonment of resident were found unsubstantiated.

The visit was a follow-up to deficiencies noted during Complaint Control #29-AS-20210420120111 investigation visit conducted on 04/12/2023.

The facility failed to notify the Department in writing within five working days of the initiation of hospice care services for approximately 15 residents placed on hospice from 1/20/2022 through 1/31/2023, which poses a potential health and safety risk. The facility currently has a hospice care waiver of 20 and 10 residents are currently receiving hospice services.

Complaint was substantiated based on multiple staff interviews, observations, and photographic evidence showing residents left in soiled diapers, unclean premises including feces and urine in resident rooms and bathrooms, and an unlocked medication cart posing immediate health and safety risks.

The investigation substantiated that residents were left in soiled diapers for extended periods, the facility premises were not kept clean and sanitary at all times, and medication carts were found unlocked and unattended, posing health and safety risks.

No deficiencies were observed during the visit. All infection control protocols were implemented and followed, including screening, PPE use, social distancing, cleaning, and staff training.

The visit was triggered by complaint #29-AS-20210614172310. The complaint was investigated and deficiencies were substantiated related to care plan updates and safety hazards.

The facility failed to update Resident 1's care plan timely after multiple changes in condition, including multiple falls and new medical instructions. Additionally, the facility allowed residents with dementia access to an electric tea kettle, posing a potential health and safety risk.

The facility was found to be in good repair with no deficiencies noted. Infection control measures, fire safety equipment, and resident accommodations were all satisfactory. A mitigation plan had been submitted previously.