Inspection Reports for Westmont of Santa Barbara

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.

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.

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.

A Case Management visit was conducted to address deficiencies noted during a Case Management – Incident visit on the same day.

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.

An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements at the Residential Care Facility for the Elderly.

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.

Unannounced complaint investigation visit conducted due to allegations regarding staff communication with authorized representatives, resident reassessment, and proper feeding of a resident.

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.

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.

A Case Management visit was conducted to address deficiencies noted during a prior complaint investigation visit on 11/08/2024.

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.

The visit was a follow-up to deficiencies noted during Complaint Control #29-AS-20241104104759 investigation visit conducted on 11/08/2024.

The visit was a Case Management - Annual Continuation inspection to review compliance with licensing requirements, including medication inventory, resident records, and facility conditions.

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.

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.

No deficiencies were noted during the inspection. The Licensing Program Analyst reviewed multiple resident records and conducted entrance and exit interviews.

The inspection was an unannounced required annual inspection of the Residential Care Facility for the Elderly (RCFE) to evaluate compliance and facility conditions.

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.

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.

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.

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.

An unannounced case management visit was conducted to issue additional deficiencies discovered while investigating complaints and reviewing incident reports related to medication errors and a bus accident at the facility.

The investigation found that 21 residents did not receive their prescribed morning medications 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.

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 morning medications on 5/27/2024, and the bus accident on 3/8/2024 was not reported as required. The complaint investigation confirmed these issues and substantiated deficiencies.

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.

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.

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.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-07-11 regarding medication mismanagement and refill issues at the facility.

The investigation substantiated that staff mismanaged resident medications and failed to ensure timely medication refills, posing health and safety risks. Other allegations regarding medication record accuracy, following doctor's orders, and emergency preparedness training were unsubstantiated.

The complaint was substantiated regarding staff mismanaging resident's medication and not ensuring timely medication refills. Other allegations about medication record accuracy, following doctor's orders, and emergency preparedness training were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-05-15 regarding failure to provide resident records, unsanitary room conditions, mal odors, and failure to safeguard resident belongings.

The investigation substantiated that the facility failed to provide a complete copy of resident records to the responsible party, did not maintain clean sanitary conditions in a resident's room, and failed to safeguard resident personal belongings, resulting in missing and damaged items. Two other allegations regarding soiled clothing and medication dispensing were unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for allegations that staff did not provide resident's personal representative with a copy of records, did not maintain clean sanitary conditions in resident's room, and did not safeguard resident's personal belongings. The allegations regarding residents being left in soiled clothing and medications not dispensed as prescribed were unsubstantiated.

An unannounced complaint investigation was conducted due to an allegation that staff did not meet a resident's health needs while in care, specifically regarding inadequate wound care leading to osteomyelitis in a resident's right great toe.

The investigation found insufficient evidence to substantiate the allegation. Interviews and record reviews indicated that the wound developed while the resident was at a Skilled Nursing Facility and that home health nurses were responsible for wound care at the facility. The allegation was deemed unsubstantiated.

The complaint alleged that staff did not meet a resident's health needs, specifically that Resident 1 did not receive appropriate wound care resulting in osteomyelitis. The allegation was investigated through interviews with facility staff, hospital and home health nurses, and review of medical records. The allegation was found to be unsubstantiated.

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.

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.

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.

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.

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.

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.

The visit was a Case Management - Annual Continuation inspection conducted to review staff records, resident medication administration, and compliance with regulations.

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.

The visit was a Case Management - Annual Continuation inspection to review residents' records and ensure compliance with licensing requirements.

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.

An unannounced required Annual Inspection was conducted to evaluate the facility's compliance with regulations as a Residential Care Facility for the Elderly (RCFE).

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.

Unannounced complaint investigation visit conducted to address allegations that staff yell at residents and do not provide adequate food service.

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.

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.

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.

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.

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.

The visit was a Case Management follow-up to address deficiencies noted during a complaint investigation conducted on 05/17/2023.

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.

The visit was conducted to address deficiencies noted during Complaint Control #29-AS-20230512135542 investigation.

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.

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.

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.

The visit was a Case Management follow-up to address deficiencies noted during a prior complaint investigation visit conducted on 12/20/2022.

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.

The visit was conducted to address deficiencies noted during Complaint Control #29-AS-20221215114140 investigation.

The visit was a Case Management visit to address deficiencies noted during a prior complaint investigation conducted on 11/30/2022.

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.

The visit was related to deficiencies noted during Complaint Control #29-AS-20221121125215 investigation visit conducted on 11/30/2022.

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.

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.

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.

An unannounced complaint investigation was conducted due to an allegation that staff mismanaged residents' medication, specifically missing fentanyl patches on residents.

The investigation found that fentanyl patches were missing on three residents at times, but interviews and record reviews indicated patches often fall off and were replaced appropriately. The allegation was deemed unsubstantiated.

The complaint alleged staff mismanaged residents' medication with missing fentanyl patches on Resident 1, Resident 2, and Resident 3. Interviews with hospice staff, facility staff, and residents, as well as record reviews, showed patches sometimes fell off but were replaced and managed properly. The complaint was unsubstantiated.

An unannounced one-year Infection Control Inspection visit was conducted as a required annual inspection of the Residential Care Facility for the Elderly (RCFE).

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.

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.

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.

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.

The inspection was an unannounced complaint investigation visit conducted in response to an allegation of neglect/lack of supervision resulting in multiple falls and injuries to facility Resident #1 (R1) between 08/07/2021 and 08/16/2021.

The investigation substantiated the allegation that R1 sustained head injuries requiring hospitalization from multiple falls due to the facility's failure to provide proper supervision and follow its protocols. The facility failed to adequately monitor and address R1's agitation and exit-seeking behaviors, and did not provide a bed alarm until after the second fall. A $500 immediate civil penalty was assessed.

The complaint was substantiated. The allegation involved neglect/lack of supervision leading to multiple falls and serious injuries to Resident #1. The investigation included interviews with staff, witnesses, medical providers, and review of medical and facility records. No crime report was found related to the allegation.

An unannounced One Year Infection Control Annual visit was conducted to evaluate compliance with infection control and staff criminal record clearance requirements.

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.