Inspection Reports for
Casa Dorinda
300 HOT SPRINGS RD., SANTA BARBARA, CA, 93108
Back to Facility ProfileCitations (last 6 years)
Citations (over 6 years)
5.5 citations/year
Citations are regulatory findings recorded during state inspections.
38% worse than California average
California average: 4 citations/yearCitations per year
16
12
8
4
0
Occupancy
Latest occupancy rate
85% occupied
Based on a October 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Citations: 1
Date: Nov 18, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to a resident fall incident involving failure to implement a bed alarm as part of the fall care plan.
Complaint Details
The investigation was triggered by a complaint regarding Resident 1's fall on 9/27/25. The complaint was substantiated as the bed alarm was not activated as required, contributing to the fall and injury.
Findings
The facility failed to ensure a bed alarm was turned on for Resident 1 while in bed, resulting in the resident falling and sustaining an acute displaced right hip fracture. Interviews and record reviews confirmed noncompliance with the facility's policy on alarm use and supervision.
Citations (1)
F 0689: The facility failed to follow their fall care plan policy by not activating the bed alarm for Resident 1, leading to a fall and acute displaced right hip fracture. Staff interviews revealed inconsistent alarm checks and failure to turn the alarm back on after care activities.
Report Facts
Resident falls: 32
Resident falls: 9
Fall Risk Score: 22
Fall Risk Assessment date: Jul 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding Resident 1's fall history and alarm policy noncompliance | |
| Assistant Director of Nursing | Interviewed about fall incident and subsequent resident assessment | |
| LN 1 | Licensed Nurse | Interviewed about bed alarm use and procedures |
| LN 2 | Licensed Nurse | Nurse on duty during Resident 1's fall and interviewed about incident |
| CNA 1 | Certified Nursing Assistant | Interviewed about bed alarm checks and use on day of fall |
Inspection Report
Annual Inspection
Census: 307
Capacity: 360
Citations: 1
Date: Oct 8, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements at the Continuing Care Retirement Community.
Findings
The facility was found to be in good repair with adequate food service and activity programs. One Type A deficiency was cited related to medication administration where a resident was given the wrong medication, posing an immediate health and safety risk.
Citations (1)
CCR 87465(c)(2) Incidental and Medical Care: Staff 1 passed the wrong medications to Resident 1 who ingested them before intervention. This poses an immediate health and safety risk to residents.
Report Facts
Fire extinguishers observed: 8
Dining capacity: 80
Medication count: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian McCague | Executive Director | Participated in the inspection |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection |
| Kelly Burley | Licensing Program Manager | Named in report |
| Therese Brown | Senior Director of Health Services | Greeted Licensing Program Analyst upon arrival |
Inspection Report
Census: 349
Capacity: 360
Citations: 0
Date: Feb 20, 2025
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident/death report received on 2025-02-18.
Findings
Based on record review and interviews, no evidence was found to suggest neglect or lack of supervision contributed to the resident's death. No citations were issued at this time.
Inspection Report
Annual Inspection
Citations: 9
Date: Dec 5, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and quality of care at Casa Dorinda nursing home.
Findings
The facility was found deficient in multiple areas including incomplete and outdated care plans for inappropriate behaviors, failure to follow up on psychiatric consultation orders, inadequate monitoring of a resident's foot drop, improper narcotics reconciliation, improper storage and labeling of medications, food safety violations, failure to submit accurate staffing data to CMS, and failure to observe proper hand hygiene by nursing staff.
Citations (9)
F 0656: The facility failed to ensure specific inappropriate behavior was documented as required in the care plan for Resident 9, resulting in inadequate monitoring and intervention.
F 0657: The facility failed to update Resident 9's care plan to reflect episodes of inappropriate behavior, potentially affecting effective interventions and quality of life.
F 0658: The facility failed to follow up on a doctor's recommendation for psychiatric consultation for Resident 9, risking unattended psychosocial health care needs.
F 0688: The facility failed to monitor and assess Resident 15's development of foot drop, risking reduced mobility and potential contractures.
F 0755: The facility failed to ensure narcotics reconciliation counts were properly conducted and signed by two licensed nurses, risking inaccurate counts and drug diversion.
F 0761: The facility failed to properly store and label biologicals and medications of discharged residents, risking diversion of medications.
F 0812: The facility failed to follow food safety requirements by mislabeling prepared foods and having sanitizing solutions below recommended concentrations, risking foodborne illness.
F 0851: The facility failed to run required payroll-based journal reports to ensure CMS received accurate staffing data, resulting in missing RN hours and licensed nursing coverage data for June 2024.
F 0880: The facility failed to ensure proper handwashing by nurse RN 2 between vital signs and medication pass, risking cross contamination and infection spread.
Report Facts
Deficiencies cited: 9
Narcotic count missing signatures: 5
Sanitizing solution concentration: 100
Sanitizing solution concentration: 200
Sanitizing solution concentration: 400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN3 | Registered Nurse | Acknowledged failure to document inappropriate behavior and psychiatric consultation order for Resident 9. |
| RN 2 | Registered Nurse | Observed failing to perform proper hand hygiene and acknowledged missing narcotic count signatures. |
| DON | Director of Nursing | Acknowledged failure to submit accurate staffing reports to CMS. |
| ADON | Assistant Director of Nursing | Acknowledged foot drop observation and planned to obtain doctor order for rehab evaluation. |
| ReD | Director of Rehabilitation | Concurred with foot drop finding and need for timely intervention. |
| DA1 | Dietary Aide | Acknowledged food containers were mislabeled with no date prepared or use-by date. |
| DA 2 | Dietary Aide | Conducted sanitizing solution testing and noted discrepancies in concentration. |
| SC | Sous Chef | Acknowledged possible inadequate disinfection process due to sanitizing solution issues. |
Inspection Report
Annual Inspection
Citations: 2
Date: Nov 5, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards related to resident care and facility operations.
Findings
The facility failed to develop and implement a comprehensive care plan for Resident 1's burn wounds, lacking required wound measurements and documentation. Additionally, the facility did not meet professional standards by failing to assess and document the burn wounds according to policy and standards of practice.
Citations (2)
F656 Develop/Implement Comprehensive Care Plan: The facility failed to ensure Resident 1's burn wound care plan included wound measurements and documentation requirements to monitor wound progression. The wounds were only measured and documented once on 10/6/24, despite policy requiring weekly documentation.
F658 Services Provided Meet Professional Standards: The facility failed to implement standards of practice by not assessing and documenting Resident 1's burn wounds according to policy and professional standards. Documentation was only performed once, and weekly observations were not initiated as required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding Resident 1's burn wound care and documentation. | |
| Assistant Director of Nursing | Interviewed regarding the care plan for Resident 1's burn wounds. |
Inspection Report
Annual Inspection
Census: 354
Capacity: 360
Citations: 0
Date: Oct 23, 2024
Visit Reason
The inspection was an unscheduled, required annual evaluation visit to assess compliance with Title 22 regulations for a Residential Care Facility for the Elderly (RCFE) Continuing Care Retirement Community (CCRC).
Findings
The facility was found to be in compliance with health and safety regulations, with clean and well-maintained physical plant areas, appropriate food service operations, adequate resident accommodations, and proper medication storage and administration. No irregularities or deficiencies were noted during the inspection.
Report Facts
Capacity: 360
Census: 354
Non-ambulatory residents allowed: 144
Hospice care waiver: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Phillips | Licensing Program Analyst | Conducted the inspection and evaluation visit |
| Therese Brown | Director of Health Services | Facility representative met during inspection |
| Brian McCague | Administrator | Facility administrator mentioned with qualifications |
Inspection Report
Complaint Investigation
Capacity: 360
Citations: 0
Date: Jul 10, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations including neglect causing injury, failure to seek timely medical treatment, drastic weight loss, and inadequate assistance to residents.
Complaint Details
The complaint involved allegations that a resident sustained injury due to neglect, staff did not seek timely medical treatment for a resident's ingrown toenail, a resident experienced drastic weight loss due to neglect, and staff did not provide adequate assistance to another resident. The investigation found insufficient evidence to support these allegations, and all were unsubstantiated.
Findings
All allegations were investigated through record reviews, staff interviews, and documentation. The investigation found insufficient evidence to substantiate any neglect or failure in care. The allegations were deemed unsubstantiated.
Report Facts
Facility Capacity: 360
Census: 366
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian McCague | Administrator | Met during investigation and named in report |
| Brian Phillips | Licensing Program Analyst | Conducted complaint investigation |
Inspection Report
Routine
Citations: 3
Date: Apr 12, 2024
Visit Reason
The inspection was conducted to assess compliance with food and nutrition service regulations, including sanitation, menu accuracy, and portion control in the skilled nursing facility.
Findings
The facility failed to ensure proper sanitation of the main kitchen's high temperature dish machine and three-compartment sink, resulting in potential foodborne illness risks. Additionally, the facility did not consistently serve correct portion sizes for regular diet orders and improperly located sanitizer dispensing equipment in a hand washing sink.
Citations (3)
F0801: The facility failed to ensure the Registered Dietitian provided sufficient oversight of the main kitchen's high temperature dish machine and three-compartment sink sanitation, resulting in inadequate monitoring and potential foodborne illness risks.
F0803: The facility failed to ensure menus met nutritional needs and that correct portion sizes were served for 20 residents on regular diets, risking inadequate nutrition.
F0812: The facility failed to maintain sanitary conditions in food and nutrition services, including improper dish machine temperatures, ineffective use of the three-compartment sink, and sanitizer dispensing tube located in a hand washing sink.
Report Facts
Logged temperature entries below standard: 23
Logged temperature entries below standard: 59
Logged temperature entries below standard: 10
Residents affected: 20
Sanitizer concentration: 100
Inspection Report
Annual Inspection
Census: 354
Capacity: 360
Citations: 0
Date: Oct 26, 2023
Visit Reason
The visit was an unannounced required 1-Year Annual facility site inspection to assess compliance with regulations and ensure health and safety standards at the facility.
Findings
The facility was found to be in compliance with health and safety regulations, with no deficiencies cited. The inspection covered kitchens, common areas, outdoor spaces, bedrooms, restrooms, and infection control measures. A continuation visit is needed to review facility records and resident documentation.
Report Facts
Fire clearance for non-ambulatory residents: 144
Hospice waiver capacity: 6
Food supply duration: 7
Fire extinguisher service year: 2023
Hot water temperature range: 105-120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian McCague | Administrator | Facility representative met during inspection |
| Therese Brown | Senior Director of Health Services | Facility representative met during inspection |
| Brian Phillips | Licensing Program Analyst | Conducted the inspection |
| Kelly Burley | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 337
Capacity: 360
Citations: 0
Date: Jun 1, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2023-04-20 regarding resident care issues including soiled diapers, medication assistance, medication training, and record maintenance.
Complaint Details
The complaint investigation addressed four allegations: residents left in soiled diapers for extended periods, improper medication assistance, inadequate medication training for staff, and improper maintenance of resident records. All allegations were deemed unsubstantiated after interviews, record reviews, and observations.
Findings
All allegations were investigated and found to be unsubstantiated due to insufficient evidence. Staff and residents denied the claims, medication records and training documentation were adequate, and resident records were properly maintained.
Report Facts
Capacity: 360
Census: 337
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Phillips | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Therese Brown | Director of Health Services | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 356
Capacity: 360
Citations: 0
Date: Mar 28, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff was financially abusing residents in care.
Complaint Details
The complaint alleged that Staff 1 financially abused Resident 1 and Resident 2 by soliciting money due to personal financial problems. The investigation included interviews with residents, staff, responsible parties, and visitors. No direct evidence was found, and the allegation was deemed unsubstantiated.
Findings
The investigation found insufficient evidence to prove the allegation of financial abuse by staff. Interviews with residents, responsible parties, and visitors revealed only rumors without direct evidence, leading to an unsubstantiated finding.
Report Facts
Capacity: 360
Census: 356
Inspection Report
Routine
Citations: 9
Date: Oct 20, 2022
Visit Reason
Routine inspection of Casa Dorinda nursing home to assess compliance with healthcare regulations including medication administration, nutritional care, pharmaceutical services, food safety, and therapeutic diet management.
Findings
The facility had multiple deficiencies including failure to ensure interdisciplinary team approval for medication self-administration, inaccurate nutritional monitoring and care planning, improper pharmaceutical services including expired and uncontrolled medications, inappropriate use of antipsychotic medication, insufficient food service staff competencies, improper food preparation and handling, and unsafe food storage and sanitation practices.
Citations (9)
F 0554: The facility failed to ensure an interdisciplinary team meeting was conducted for self-administration of medication for one resident, risking unsafe medication use without approval.
F 0578: The facility failed to update medical records to reflect current life-sustaining treatment wishes for one resident, risking inappropriate emergency care.
F 0692: The facility failed to accurately monitor nutritional status for one resident, including missed weight loss referral, inaccurate care plan goals, and lack of documentation of nutrition intervention intake.
F 0755: The facility failed to follow policies for disposition and reconciliation of expired and controlled medications, including unsecured narcotics and expired inhalation solutions.
F 0757: The facility failed to assess one resident's use of antipsychotic medication with dementia diagnosis, placing the resident at increased risk of death.
F 0802: The facility failed to employ competent food service staff, resulting in improper dish machine temperature monitoring, inadequate sanitizer concentration in pot washing, and incorrect thermometer calibration.
F 0804: The facility failed to ensure a cook followed the puree egg omelet recipe, resulting in a meal with less nutritive value than planned for a resident.
F 0808: The facility allowed the Registered Dietitian to write therapeutic diet and supplement orders without physician authorization, exceeding the RD's scope of practice under state law.
F 0812: The facility failed to ensure safe food handling by storing expired leftover lentil soup without documented safe cooling and by having an unclean ice machine dispenser in a resident kitchenette.
Report Facts
Weight measurements: 104
Weight measurements: 110
Sanitizer concentration: 100
Dish machine temperature: 80
Dish machine temperature: 180
Medication expiration date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Interviewed regarding medication self-administration and POLST documentation |
| DON | Director of Nursing | Interviewed regarding medication self-administration, pharmaceutical services, and RD order writing privileges |
| RD | Registered Dietitian | Interviewed regarding nutritional assessments, care plans, and order writing privileges |
| DW 4 | Dishwasher | Observed and interviewed regarding dish machine temperature monitoring |
| Chef 1 | Chef | Interviewed regarding dish machine logs, sanitizer concentration, and thermometer calibration |
| TLS | Team Lead Supervisor | Interviewed regarding food preparation and staff competencies |
| MDS Coordinator | MDS Coordinator | Interviewed regarding nutrition care plan updates |
| LN 2 | Licensed Vocational Nurse | Interviewed regarding pharmaceutical services and narcotic disposal |
Inspection Report
Annual Inspection
Capacity: 325
Citations: 0
Date: Oct 12, 2022
Visit Reason
An unannounced infection control annual inspection was conducted to evaluate compliance with infection control policies and procedures.
Findings
No deficiencies were observed during the visit. The facility follows infection control policies including screening, masking, social distancing, and staff training. The physical plant and safety equipment were inspected and found compliant.
Report Facts
Residents present: 346
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian McCague | Administrator | Named as facility administrator during inspection |
| Therese Brown | Senior Director of Health Services | Met with licensing analysts and responsible for infection control |
| Diego Cortez | Licensing Evaluator | Conducted the inspection |
| Kelly Burley | Supervisor | Supervised the inspection |
Inspection Report
Complaint Investigation
Citations: 1
Date: Oct 4, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that uncleared staff were working at the facility without fingerprint clearance.
Complaint Details
The complaint was substantiated. The allegation involved uncleared staff working at the facility without fingerprint clearance. A citation and civil penalty were not issued because the issue was cited previously on 9/21/2022.
Findings
The allegation that staff were working without fingerprint clearance was substantiated. Staff member S1 was found working without clearance and was removed from the schedule and later terminated. A citation and civil penalty were not issued as this was previously cited on a 9/21/2022 case management visit.
Citations (1)
Uncleared staff worked at the facility without fingerprint clearance, including Staff 1 (S1) who was working since December 2021. S1 was removed from the schedule on 09/21/2022 and terminated on 10/04/2022.
Report Facts
Facility census: 348
Facility capacity: 325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian McCague | Administrator | Met with licensing analysts during the complaint investigation and involved in findings related to uncleared staff |
Inspection Report
Citations: 1
Date: Sep 21, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on a confirmation of removal notification for one staff member and to review fingerprint clearance compliance.
Findings
The facility was found to have five staff members who worked prior to obtaining fingerprint clearance, posing an immediate health and safety risk. The administrator confirmed termination and removal of staff without clearance, and a plan of correction was accepted during the visit.
Citations (1)
87355(e)(1) CRIMINAL RECORD CLEARANCE: Five staff members worked in the facility prior to obtaining fingerprint clearance, violating Health and Safety Code Section 1569.17(b). This posed an immediate health and safety risk to residents.
Report Facts
Staff without fingerprint clearance: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian McCague | Administrator | Named in relation to staff fingerprint clearance and termination issues |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Kelly Burley | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Capacity: 325
Citations: 0
Date: Dec 20, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2020-01-17 regarding multiple allegations against staff at the facility.
Complaint Details
The complaint included allegations of staff failing to supervise residents during showers, not washing residents' hair, not providing laundry service, speaking inappropriately to residents, and stealing residents' personal items. All allegations were found unsubstantiated based on interviews and evidence.
Findings
The investigation found all allegations unsubstantiated after interviews with residents and staff. Residents reported no issues with supervision during showers, hair washing, laundry service, staff communication, or theft of personal items.
Report Facts
Facility Capacity: 325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation |
| Jackie Castaneda | Director of Personal Care | Met with investigator during the visit |
| Brian McCague | Administrator | Facility administrator named in report header |
| Kelly Burley | Supervisor | Supervisor overseeing the investigation |
| Therese Brown | Senior Director of Health Services | Met with investigator during the visit |
Inspection Report
Annual Inspection
Census: 322
Capacity: 325
Citations: 0
Date: Oct 12, 2021
Visit Reason
An unannounced onsite one-year infection control annual visit was conducted as a required annual inspection.
Findings
The facility was toured and assessed for infection control and physical environment compliance. No deficiencies or citations were noted during the inspection.
Inspection Report
Census: 299
Capacity: 325
Citations: 0
Date: Aug 24, 2021
Visit Reason
The visit was a Case Management inspection initiated by the licensee to inspect existing Assisted Living remodeled apartments and newly constructed Independent Living villas, cottages, and apartments.
Findings
The Licensing Program Analyst inspected remodeled and newly constructed units across the Assisted Living and Independent Living wings. The facility campus was found to be in compliance with Title 22 regulations at the time of the visit.
Report Facts
Fire clearance capacity: 17
Fire clearance capacity: 22
Fire clearance capacity: 14
Number of remodeled apartments: 17
Number of one-bedroom apartments: 10
Number of studio apartments: 7
Number of villas: 7
Number of cottages: 5
Number of apartments: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian McCague | Administrator | Met with Licensing Program Analyst during the inspection |
| Kristin Kontilis | Licensing Program Analyst | Conducted the Case Management visit |
Inspection Report
Complaint Investigation
Citations: 6
Date: Mar 14, 2019
Visit Reason
The inspection was conducted to investigate complaints regarding failure to obtain informed consent for medication changes, incomplete care plans, improper use of psychotropic medications, expired medications and supplies, food safety violations, and inadequate vaccination education.
Complaint Details
The visit was complaint-related, investigating multiple allegations including failure to obtain informed consent for medication changes, incomplete care plans, improper psychotropic medication orders, expired medications and supplies, food safety violations, and inadequate vaccination education. The deficiencies were substantiated as noted in the findings.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent before increasing antipsychotic medication dosage, incomplete and missing care plans for residents, lack of stop dates for PRN psychotropic medications, failure to discard expired medications and supplies, improper food storage and labeling, and failure to provide documented education on influenza vaccinations to residents or their responsible parties.
Citations (6)
F 0552: The facility failed to obtain informed consent before increasing an antipsychotic medication dosage for one resident, violating the resident's right to be informed of associated risks.
F 0656: The facility failed to develop comprehensive, person-centered care plans for two residents, omitting wanderguard use and diabetes management, placing residents at risk for harm.
F 0758: The facility failed to ensure PRN psychotropic medication orders had stop dates after 14 days for two residents, risking adverse side effects from continued use.
F 0761: The facility failed to discard expired medications and supplies found in the medication room, posing potential adverse reactions to residents.
F 0812: The facility failed to remove dented cans, label opened bulk and refrigerated food items, and discard expired refrigerated food, risking foodborne illness.
F 0883: The facility failed to provide documented education regarding influenza vaccine risks and benefits to five residents or their responsible parties, violating informed consent rights.
Report Facts
Residents sampled: 13
Residents affected: 5
Residents affected: 2
Residents affected: 2
Expired medication dates: 2015
Expired medication dates: 2016
Expired medication dates: 2018
PRN medication duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged lack of informed consent documentation, missing care plans, PRN medication order issues, and expired medications |
| Licensed Nurse LN2 | Licensed Nurse | Interviewed regarding wanderguard use and care plan documentation |
| Director of Staff Development and Infection Control | Director of Staff Development and Infection Control | Interviewed regarding influenza vaccine education and documentation |
| Food Services Receiver | Food Services Receiver | Acknowledged food storage and labeling deficiencies |
| Dietician | Dietician | Acknowledged expired refrigerated juice not discarded |
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