Inspection Reports for Garden Court at Villa Santa Barbara
227 E Anapamu St, Santa Barbara, CA 93101, United States, CA, 93101
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. The most recent report from October 30, 2025, confirmed a serious incident where staff failed to respond promptly to a resident’s call button, resulting in a fall with significant injuries; a potential $10,000 fine is under review related to this event. Earlier inspections identified medication management issues, including unexplained medication counts and expired medications, which required corrective action. There was also a substantiated finding in September 2023 about delayed call button responses posing an immediate health risk. The facility showed some improvement in medication management by the latest annual inspection in January 2025, but the recent serious injury highlights ongoing concerns with timely staff response.
Deficiencies per Year
4
3
2
1
0
High
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 101
Capacity: 126
Deficiencies: 0
Oct 30, 2025
Visit Reason
The visit was an Informal Conference held to discuss complaint investigation 29-AS-20241001130402 regarding a resident's injury due to alleged staff failure to respond to a call button in a timely manner, along with a general compliance review of the facility.
Findings
The investigation revealed that staff did not respond to Resident 1's call for assistance, resulting in the resident falling and sustaining a facial laceration, hematoma, and wrist fracture. The licensee representatives discussed measures implemented to maintain compliance and address the resident's needs, including additional monitoring, staff training, and system oversight. A potential civil penalty of $10,000 for serious bodily injury is under review.
Complaint Details
Complaint alleged that facility staff did not answer Resident 1's call button in a timely manner, resulting in the resident sustaining a fracture, facial laceration, and hematoma. Investigation confirmed staff failure to respond, leading to serious bodily injury.
Report Facts
Civil penalty amount: 10000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Glock | Administrator | Facility administrator involved in the Informal Conference and discussion of complaint investigation |
| Kelly Burley | Licensing Program Manager | Attended Informal Conference and signed report |
| Kristin Kontilis | Licensing Program Analyst | Attended Informal Conference and signed report |
| Tina Tran | Wellness Director | Attended Informal Conference and discussed compliance strategies |
Inspection Report
Annual Inspection
Census: 96
Capacity: 126
Deficiencies: 1
Jan 15, 2025
Visit Reason
An unannounced required Annual Inspection was conducted to evaluate compliance with licensing regulations for the Residential Care Facility for the Elderly (RCFE).
Findings
The inspection revealed medication administration discrepancies for Resident 1, including under-administration of Senna and an extra dose of Acyclovir. Deficiencies were cited related to medication management and a plan of correction was required.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Unexplainable under-count of Resident 1's medications, posing an immediate health, safety or personal rights risk to persons in care. | Type A |
Report Facts
Census: 96
Total Capacity: 126
Plan of Correction Due Date: Jan 17, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Glock | Administrator | Met during inspection and involved in findings |
| Tina Tran | Wellness Director, RN | Met during inspection |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 126
Deficiencies: 0
Sep 6, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2023-09-18 regarding staff not assisting residents with incontinence needs, failure to keep the facility free of odor, and a resident developing a pressure injury while in care.
Findings
After multiple visits, interviews, and document reviews, the allegations were found to be unsubstantiated due to insufficient evidence. Staff were found to be responsive to residents' needs, no foul odors were confirmed, and the alleged pressure injury was determined to be moisture-associated skin damage that had healed.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to assist with incontinence, facility odor issues, and a pressure injury. Investigations included interviews with staff, residents, visitors, hospice personnel, and review of documentation. The pressure injury was identified as moisture-associated skin damage, not a pressure ulcer.
Report Facts
Facility capacity: 126
Census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation and visits |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation report |
| Robert Glock | Administrator | Facility administrator met during the investigation |
| Tina Tran | Wellness Director | Met during the investigation and provided information |
Inspection Report
Complaint Investigation
Capacity: 126
Deficiencies: 0
May 29, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that facility staff did not meet a resident's needs, specifically concerning pressure injuries sustained by Resident 1 (R1).
Findings
The investigation found insufficient evidence to substantiate the allegation that facility staff failed to meet R1's needs. Medical and hospice records did not confirm any pressure injuries or wounds, and staff provided appropriate care. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that facility staff did not meet Resident 1's needs, including concerns about pressure injuries. The investigation included interviews, document reviews, and observations. The allegation was unsubstantiated due to lack of evidence of pressure injuries or wounds in hospital and hospice records.
Report Facts
Facility capacity: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation visit and issued final findings |
| Robert Glock | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Tina Tran | Wellness Director | Wellness Director interviewed during investigation and provided information on resident care |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Follow-Up
Census: 89
Capacity: 126
Deficiencies: 0
Mar 6, 2024
Visit Reason
The visit was an unannounced Case Management site visit conducted to follow up on an immediate exclusion served to Staff #1 (S1) and to confirm removal of the excluded staff member from the facility.
Findings
The Administrator confirmed that Staff #1 has not worked at the facility since 4/22/2018 and that the staff member was not present during the visit. No citations were issued during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Glock | Administrator | Met with Licensing Program Analyst during the visit and provided personnel roster to verify staff exclusion. |
| Kristin Kontilis | Licensing Program Analyst | Conducted the unannounced Case Management site visit. |
| Karolyn Sorenson | Regional Operations Specialist | Met with Licensing Program Analyst and Administrator during the visit. |
Inspection Report
Annual Inspection
Census: 88
Capacity: 126
Deficiencies: 2
Feb 27, 2024
Visit Reason
An unannounced required Annual Inspection was conducted to evaluate compliance with licensing requirements for the Residential Care Facility for the Elderly (RCFE).
Findings
The inspection revealed medication management deficiencies including unexplainable overcounts of medications for Resident 1 and the presence of eight expired medications. Plans of correction were required to address these issues by 02/29/2024.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Unexplainable overcount of Resident 1's medications posing immediate health, safety, or personal rights risk. | Type A |
| Presence of eight bottles of expired medications belonging to Resident 1 posing immediate health and safety risk. | Type A |
Report Facts
Expired medications: 8
Medication overcount: 21
Medication overcount: 34
Medication count: 46
Plan of Correction Due Date: Feb 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Glock | Executive Director | Met with Licensing Program Analyst during inspection and involved in medication recount |
| Kristin Kontilis | Licensing Program Analyst | Conducted the unannounced annual inspection and authored the report |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 126
Deficiencies: 0
Dec 11, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were refusing to allow a resident to remove their personal belongings from the facility.
Findings
The investigation found that the allegation was unsubstantiated. The Administrator and Wellness Director confirmed that the resident was responsible for themselves with no POA or Responsible Party on file, and after communication with the resident's family, the resident's belongings were eventually removed from the facility.
Complaint Details
The complaint alleged that staff refused to allow a resident to remove their personal belongings. The investigation included interviews and document reviews, concluding the allegation was unsubstantiated.
Report Facts
Facility capacity: 126
Resident census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Rick Olds | Administrator | Interviewed regarding the complaint and investigation |
| Bill Ferguson | Business Director | Met during the inspection visit |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 126
Deficiencies: 1
Sep 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff do not answer residents' call buttons in a timely manner.
Findings
The allegation that staff did not respond to a resident's call pendant in a timely manner was substantiated. Records showed call responses took between 10-29 minutes, exceeding the facility's goal of 3-5 minutes, posing an immediate health and safety risk.
Complaint Details
The complaint was substantiated based on interviews, record review, and observation. The resident's call pendant was pressed multiple times with delayed responses of 10-29 minutes, which posed an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident’s call buttons were responded to timely, violating CCR 87468.2(a)(4) regarding residents' personal rights to care and supervision. | Type A |
Report Facts
Call pendant occurrences: 8
Call response time (minutes): 10
Call response time (minutes): 29
Census: 84
Total capacity: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Kelly Burley | Licensing Program Manager | Named in relation to the deficiency and plan of correction |
| Rick Olds | Administrator | Facility administrator interviewed during the investigation |
| Mark Cortes | Administrator | Administrator met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 126
Deficiencies: 0
Jun 2, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that staff spoke inappropriately towards residents and did not treat residents with dignity.
Findings
The investigation included interviews with residents, staff, and administrators. Evidence did not substantiate the allegations; residents reported being happy with staff and no inappropriate behavior was confirmed. An all-staff in-service training was conducted to reinforce residents' rights and staff interaction expectations.
Complaint Details
The complaint alleged staff spoke rudely and inappropriately to residents, including a staff member (S1) using a yelling tone. Interviews and investigation found no substantiation of these claims. The allegation was determined to be unsubstantiated.
Report Facts
Estimated Days of Completion: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Rick Olds | Administrator | Met with Licensing Program Analyst during investigation and provided statements |
| Karolyn Sorenson | Administrator | Named as facility administrator in report header |
Inspection Report
Original Licensing
Census: 66
Capacity: 126
Deficiencies: 0
Nov 15, 2022
Visit Reason
An announced Change of Ownership Prelicensing Inspection was conducted to license the facility as a Residential Care Facility for the Elderly (RCFE).
Findings
The facility was found to be in good repair, clean, and compliant with licensing requirements per Title 22 California Code of Regulations. Fire safety and personal accommodations were inspected with no deficiencies noted.
Report Facts
Fire extinguishers: 40
Hospice waiver residents: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rick Olds | Administrator | Met with during inspection and mentioned in narrative |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection |
| Karolyn Sorenson | Administrator | Named as facility administrator |
| Kelly Burley | Licensing Program Manager | Named in report header and footer |
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