Inspection Report Summary
Most inspections found deficiencies related to resident care, supervision, medication management, and safety, with several complaint investigations substantiating issues such as inadequate supervision leading to falls and injuries, delayed abuse reporting, and medication errors. The facility received a $500 civil penalty in January 2024 for inadequate supervision resulting in a resident elopement and injury, and a civil penalty related to caregiver clearance violations in September 2024. The most recent report from July 14, 2025, cited a deficiency for failure to report multiple resident falls, including one that preceded a resident’s death, indicating ongoing challenges with incident reporting. Earlier annual inspections in April 2024 and April 2025 were clean with no deficiencies, showing some periods of compliance between complaint investigations. Several complaint investigations found substantiated issues, but some allegations were unsubstantiated, and there is no clear pattern of consistent improvement or decline over time.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 37
Capacity: 50
Deficiencies: 1
Jul 14, 2025
Visit Reason
An unannounced case management incident visit was conducted regarding a death on 2025-06-25 at the facility.
Findings
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.
Complaint Details
The visit was triggered by a complaint related to a resident's death following multiple falls, with failure to report incidents as required.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit written incident reports to the licensing agency regarding Resident 1's falls, including the fall on 2025-06-25. | Type A |
Report Facts
Facility capacity: 50
Resident census: 37
Plan of Correction due date: Jul 15, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Administrator | Met with Licensing Program Analyst during the visit and provided information about the incident |
| Kristin Kontilis | Licensing Program Analyst | Conducted the unannounced case management incident visit and authored the report |
| Kelly Burley | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 37
Capacity: 50
Deficiencies: 0
Apr 22, 2025
Visit Reason
An unannounced required Annual Inspection was conducted to assess compliance with licensing requirements at the facility.
Findings
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.
Report Facts
Residents on hospice: 8
Non-ambulatory residents allowed: 39
Bedridden residents allowed: 11
Resident rooms: 40
Shared bedrooms: 4
Shared bathrooms: 7
Fire extinguishers on first floor: 3
Fire extinguishers on second floor: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection |
| Tyler Barnes | Administrator | Facility administrator not available at time of visit |
| Mericare Pelare | Business Office Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 50
Deficiencies: 3
Sep 24, 2024
Visit Reason
This was an unannounced complaint investigation visit triggered by allegations including inadequate supervision of residents, illegal eviction, and improper abuse reporting.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Staff did not provide adequate supervision to R1, resulting in aggressive incidents posing immediate health and safety risks. | Type A |
| Verbal eviction was issued to R1 without providing the required written notice to the responsible party. | Type A |
| Failure to report suspected physical abuse within the required 24-hour timeframe, with reports delayed up to 11 days. | Type A |
Report Facts
Capacity: 50
Census: 34
Deficiencies cited: 3
Incident dates: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Administrator | Named in findings related to supervision, eviction, and abuse reporting |
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 50
Deficiencies: 3
Sep 6, 2024
Visit Reason
An unannounced case management visit was conducted to investigate medication errors and review incident reports related to failure to provide prescribed medications to multiple residents.
Findings
Multiple medication errors were identified where several residents did not receive their prescribed medications on 06/30/2024 and 07/15/2024, posing immediate health and safety risks. Additionally, the facility failed to ensure proper criminal record clearance transfers for private and temporary caregivers, resulting in a civil penalty.
Complaint Details
The visit was complaint-related, triggered by incident reports of medication errors affecting multiple residents. The complaint was substantiated with findings of medication administration failures and regulatory violations.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Multiple residents did not receive their medication as prescribed, posing an immediate health and safety risk. | Type A |
| Thirteen private and/or temporary caregivers were not associated with the facility, violating criminal record clearance transfer requirements and posing an immediate health and safety risk. | Type A |
| Failure to submit a written report within seven days of a medication error involving 12 residents, posing a potential health and safety risk. | Type B |
Report Facts
Residents affected by medication errors: 12
Private/temporary caregivers without proper association: 13
Civil penalty: Civil penalty assessed for criminal record clearance transfer violation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Barnes | Administrator | Met with Licensing Program Analyst during investigation and discussed medication assistance importance. |
| Kristin Kontilis | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the licensing evaluation. |
Inspection Report
Annual Inspection
Census: 36
Capacity: 50
Deficiencies: 0
Apr 26, 2024
Visit Reason
An unannounced required Annual Inspection was conducted to evaluate the facility's compliance with licensing regulations and assess the physical environment, resident care, and safety measures.
Findings
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.
Report Facts
Residents on hospice: 9
Fire inspection date: May 10, 2021
Resident rooms: 40
Shared bedrooms: 4
Shared bathrooms: 7
Food supply duration (perishable): 2
Food supply duration (non-perishable): 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Andrea Katz | Administrator | Facility administrator who resigned prior to inspection |
| Jovany Guerra | Senior Generations Program Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 50
Deficiencies: 1
Jan 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to allegations that staff did not provide adequate supervision to a resident and did not address a resident's change in medical condition.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Licensee did not ensure supervision was provided to R1; as a result R1 eloped from facility. | Type A |
Report Facts
Civil penalty amount: 500
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation |
| Jovany Guerra | Senior Resident Care Director | Interviewed during investigation and involved in findings |
| Andrea Katz | Administrator | Facility administrator not available at time of arrival |
| Kelly Burley | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 50
Deficiencies: 2
Dec 20, 2023
Visit Reason
This was an unannounced complaint investigation visit triggered by a complaint received on 2021-10-13 regarding multiple allegations including inadequate diapering, medication management, and other resident care concerns at Oak Cottage of Santa Barbara Memory Care.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow physician's orders for PRN medication administration, posing immediate health and safety risk. | Type A |
| Double diapering residents, posing potential health and safety risk. | Type B |
Report Facts
Capacity: 50
Census: 37
Deficiencies cited: 2
Plan of Correction Due Dates: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
| Jovany Guerra | Senior Resident Care Director | Interviewed during investigation regarding allegations |
| Andrea Katz | Administrator | Facility administrator mentioned in relation to resident behavior and eviction counseling |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 50
Deficiencies: 3
Apr 12, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including residents left in soiled diapers for a long period, unclean facility premises, and unsecured centrally stored medication.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure residents' incontinence care needs were met, posing potential health and safety risks. | Type B |
| Failure to maintain the facility in a clean, safe, sanitary, and good repair condition at all times. | Type B |
| Failure to keep centrally stored medicines in a safe and locked place accessible only to authorized employees. | Type A |
Report Facts
Capacity: 50
Census: 36
Deficiency count: 3
Plan of Correction Due Date: Apr 14, 2023
Plan of Correction Due Date: Apr 17, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Katz | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Jovany Guerra | Senior Generations Program Director | Named in findings and responsible for conducting staff training on medication cart security |
| Kristin Kontilis | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Follow-Up
Census: 36
Capacity: 50
Deficiencies: 1
Apr 12, 2023
Visit Reason
The visit was a Case Management follow-up to address deficiencies noted during a prior complaint investigation visit conducted on the same date, 04/12/2023.
Findings
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 10 residents receiving hospice services and holds a hospice care waiver of 20.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the Department in writing within five working days of the initiation of hospice care services for terminally ill residents or admitting residents already receiving hospice care services. | Type B |
Report Facts
Residents placed on hospice without notification: 15
Current hospice residents: 10
Hospice care waiver capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Katz | Administrator | Met with Licensing Program Analyst during the visit and counseled on hospice care waiver requirements. |
| Jovany Guerra | Senior Generations Program Director | 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 | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 41
Capacity: 50
Deficiencies: 0
Feb 27, 2023
Visit Reason
The inspection was a required, unannounced 1-year infection control annual visit to evaluate the facility's compliance with infection control protocols.
Findings
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.
Report Facts
PPE supply: 30
Resident apartments: 40
Public rest-rooms: 4
Fire extinguisher last inspection date: Jan 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edith Martinez Flores | Business Office Director | Met with Licensing Program Analyst during the visit. |
| Benjamin Rodriguez | Building Services Director | Conducted physical plant tour with Licensing Program Analyst. |
| Andrea Katz | Administrator | Administrator in charge of infection control and staffing; not present during visit. |
| Rachael De Leon | Licensing Program Analyst | Conducted the inspection visit. |
| Kelly Burley | Licensing Program Manager | Named in report header. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 50
Deficiencies: 5
Apr 21, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/14/2021 regarding staff neglect, unmet resident needs, failure to observe changes in condition, unclean resident rooms, and lack of necessary toiletries.
Findings
The investigation substantiated multiple allegations including staff neglect resulting in multiple resident falls and injuries, failure to meet resident hygiene and toileting needs, failure to observe and document changes in resident condition, unclean resident rooms with urine odor and debris, and failure to provide necessary toiletries such as toilet paper. One allegation regarding medication assistance was unsubstantiated, and the allegation of a verbal 24-hour eviction notice was unsubstantiated but noted as improper practice. The allegation that residents were not allowed visitors was also unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations of staff neglect causing multiple falls and injuries to resident R1, failure to meet resident needs including hygiene and toileting, failure to observe changes in condition, unclean resident rooms, and lack of necessary toiletries. Allegations regarding improper medication assistance, verbal eviction notice, and visitor restrictions were unsubstantiated.
Severity Breakdown
Type A: 3
Type B: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure safe, healthful, and comfortable accommodations due to numerous falls and injuries sustained by resident R1. | Type A |
| Failure to provide care, supervision, and services that meet resident R1's individual needs, including fall risk and 1:1 care requirements. | Type A |
| Failure to observe resident R1 for changes in condition and timely notify physician, posing immediate health and safety risk. | Type A |
| Failure to maintain clean, safe, sanitary, and in good repair rooms and bathrooms for residents R1 and R2, including urine odor and debris. | Type B |
| Failure to provide hygiene items such as soap and toilet paper to residents R1 and R2. | Type B |
Report Facts
Resident falls: 16
Facility capacity: 50
Resident census: 43
Civil penalty: 500
Plan of Correction Due Date: Apr 26, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation. |
| Jovany Guerra | Generations Program Director | Interviewed during investigation; involved in care and supervision discussions. |
| Andrea Katz | Administrator | Facility administrator interviewed regarding allegations and facility practices. |
Inspection Report
Complaint Investigation
Census: 243
Capacity: 50
Deficiencies: 2
Apr 21, 2022
Visit Reason
The inspection was an unannounced visit conducted to investigate complaint #29-AS-20210614172310 regarding deficiencies in resident care and safety.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident 1's care plan was not updated timely after multiple changes in condition, including sixteen falls and new medical instructions for use of a knee immobilizer/brace and wedge pillow. | Type B |
| The facility did not ensure residents with dementia did not have access to an electric tea kettle, posing a potential health and safety risk. | Request Denied Type B |
Report Facts
Resident falls: 16
Census: 243
Total capacity: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jovany Guerra | Generations Program Director | Met with during inspection and involved in removing the electric tea kettle. |
| Jeannette Olson | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
Inspection Report
Annual Inspection
Census: 43
Capacity: 50
Deficiencies: 0
Apr 21, 2022
Visit Reason
An unannounced one-year infection control inspection was conducted as a required annual visit to evaluate compliance with health and safety regulations.
Findings
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.
Report Facts
Residents on hospice: 11
Fire extinguishers: 5
Resident rooms: 40
Shared bedrooms: 4
Shared bathrooms: 7
Perishable food supply: 2
Non-perishable food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jovany Guerra | Generation Program Director | Met with Licensing Program Analysts during the inspection |
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