Oak Cottage of Santa Barbara Memory Care.

Staff interviewed stated staff often sit next to R2 to calm them down and redirect them. Staff also stated R2 sits at different tables in the facility, but do not put anything near the chair to prevent them from leaving. Staff stated if they see R2 getting agitated and trying to get out of the chair, they know they want to be moved. On 11/18/2025 at approximately 1:38 pm–1:41 pm, LPA observed R2 and R3 in their wheelchairs at a table, with an empty chair next to each of them, obstructing an exit path from the table. LPA observed R2 attempting to stand up from the table. LPA observed two staff standing against the wall away from the table. One staff interviewed indicated the empty chair next to residents with no caregiver does appear like the chair is blocking the residents in. The staff also stated there is typically a staff in the chair next to the residents. Administrator confirmed the residents are not physically able to get up from the table on their own if the chairs are blocking them in. On 11/18/2025, LPA observed R2 and R3 three separate times during the visit sitting in their wheelchairs at the table with the empty chairs next to them, and at no time were the chairs occupied by staff. Administrator stated the chairs are not supposed to be next to the residents when they are empty and when staff are not sitting in them next to the residents during activities. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 resident to the dining area presentable, with care provided for hair, teeth, clean clothes, with socks and shoes. If a resident refuses, they try again at a another time and let their physician know if the behavior is not normal. Caregivers document if a care task did not get done. One staff noted that although R1 was showered, their hair appeared greasy the next day. Staff interviewed did not recall R1 refusing showers often or not being showered. R1’s visitor was interviewed, who indicated they observed R1’s toiletries including toothpaste, deodorant and face lotion, at the back of a cabinet inaccessible and appearing to not be used. R1’s visitor stated their toothbrush and toothpaste were new and unused for a month, showing R1’s teeth had not been brushed. Staff stated residents’ care needs are indicated in their care plan, and teeth should be brushed twice a day. Staff stated some residents use mouth swabs with mouthwash, which are a sponge on the end of a stick. Staff stated some residents do not like their teeth brushed, but they have a right to refuse and are not forced. Most staff interviewed did not recall R1 refusing care often. One staff stated R1 did not like having their teeth brushed, and on one occasion did not spit out the water for 30 minutes during teeth brushing, despite staff asking them to. R1’s visitor indicated they have found R1 “unkempt” with feces under their fingernails and sitting in wet briefs. Staff interviewed were consistent and stated no residents are in wet briefs for an extended period of time, as the care plan indicates what residents need assistance with and they are regularly checked and changed, or assisted to the toilet. A witness stated on 05/13/2025 at around 3:50 pm, they witnessed a resident in the common area calling for staff multiple times, stating they needed to use the restroom. The witness observed two caregivers engaged in a conversation instead of helping the resident. The witness informed a staff member about the situation, but stated they felt the staff were dismissive. During visits to the facility for the investigation, LPA did not observe any malodors and observed caregivers present around residents in the common areas, attending to residents. One staff stated about a year ago there was one resident who had a behavior of sticking their hand in their brief, and their family member cleaned their nails. There was no other evidence found to suggest residents were sitting in wet briefs or had dirty hands. R1’s visitor also noted they have observed R1 not properly dressed, as they were not wearing a bra or socks, and had their roommate’s pants on that were too small and tight. Staff stated some residents don’t like to wear bras, and med techs are informed if the clothing is too small so that can be communicated to the responsible party. Care staff stated the caregivers know each resident’s clothes and most items are labeled, but occasionally there are mix ups with residents’ laundry put into the wrong room that are corrected. Staff Please continue to 9099-C, Pg 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 interviews did not indicate a resident was dressed in another resident’s clothing. Staff interviewed more recently indicated clothing items are labeled and do not get mixed up, although sometimes residents leave their jackets in the common area and staff return them. R1’s visitor stated R1 was not assisted properly with feeding, such as being fed pieces that were too large or were not finger foods, even though R1 was supposed to receive assistance with feeding. Staff stated if a resident has a special diet, the kitchen is informed and the food prepared accordingly. If there are issues with a resident eating, that information is communicated to the doctor for a change diet order or for additional evaluation. Staff also stated they try to accommodate residents’ preferences. Staff stated they must provide the care services listed on the resident’s care plan. Staff indicated some residents eat with their hands. The investigation did not reveal any evidence that staff did not assist R1 with meals. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. The facility is reminded of their responsibility to provide adequate care and supervision to meet residents’ needs. On the allegation: Staff failed to safeguard residents' personal belongings. It was alleged a resident’s glasses were missing, and staff brought a visitor four different pairs that did not belong to the resident. It was alleged residents may be without their glasses, dentures and hearing aids. It was also alleged another resident takes R1’s personal items such as stuffed animals and toys. R1’s visitor stated staff do not put R1’s glasses on them unless instructed to do so. Staff interviewed indicated they are supposed to make sure hearing aids are turned on during the shift. Staff interviewed stated they did not remember R1 or any other resident losing their glasses or hearing aid. Staff interviewed indicated they have all glasses and hearing aids labeled, and the items are collected at bedtime and kept in the med tech station overnight, unless the family requests to keep the items in the room. R1’s visitor stated staff indicated R1’s roommate likes to put things away, and this accounts for why items go missing. Most staff interviewed did not remember R1’s stuffed animal, but stated there were common area activity items and stuffed animals. One staff stated they remembered R1’s stuffed animal dog was missing at one time but was found after a short amount of time, but they could not recall more details. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. The facility is reminded of their responsibility to safeguard residents’ personal belongings and ensure access to them, and provide adequate supervision to residents. Exit interview conducted and a copy of this report issued at the time of the visit.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management incident visit regarding a death on 6/25/2025. LPA met with Administrator Tyler Barnes and explained the purpose of the visit. During today’s visit, LPA obtained documents and conducted in-person interviews. On 7/7/2025, the facility submitted a death report for Resident 1 (R1) who passed away on 6/29/2025 at the local hospital. The death report stated the resident was ‘admitted to ICU on 6/25/2025, awaiting official cause of death’. At 1:16 PM, LPA spoke with Administrator Barnes who stated 9-1-1 was called for R1 when R1 sustained a fall in the facility. LPA conducted a tour of the facility including the location where R1’s fall occurred. Administrator Barnes stated on 6/30/2025 at approximately 11:00 am, R1’s Power of Attorney (POA) notified the facility receptionist that R1 passed away at the hospital in the evening of 6/29/2025. Documents obtained revealed R1 has sustained multiple falls while residing in the facility. Documents obtained further revealed the facility failed to report several of R1’s fall incidents, including R1’s fall on 6/25/2025. Due to time restraints, LPA will return at a later date to continue the investigation. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D). Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.

It was noted during interviews that R1’s one-on-one caregiver did not speak English and could not effectively communicate with the resident. Although the facility had implemented one-on-one supervision for R1 due to their known aggressive behaviors, the one-on-one staff was unable to prevent R1 from abusing another resident and could not redirect R1 to release R2’s hair. Interviews with Staff 1 (S1) revealed R1 had a strong grip on R2 leading R2 to an area adjacent from the area approximately 64 feet from where the incident first occurred. Staff stated this likely hurt R2 although Staff stated that after the incident R2 had a look on their face as though that they were in “shock” and R2 was holding the back of their head indicating they were in pain.” Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Illegal eviction. The SOC341 for the 8/29/2024 incident states R1 was picked up by their POA on 8/29/2024 at approximately 6:00 pm and R1 was discharged from the facility on 8/30/2024 due to the community being unable to meet R1’s needs. It was clarified through interview that after the incident on 8/29/2024, Executive Director Tyler Barnes through the Interim LVN Nurse Consultant directed LVN Consultant to contact facility staff to let R1’s responsible party know that R1 needed to be picked up within the next few hours or 9-1-1 would be called and R1 would be transported to the hospital and evaluated for “altered state of mind and return to baseline due to aggression and refusing medications". On 8/30/2024, Executive Director stated POA was notified via telephone that due to multiple aggressions and multiple medication refusals, that R1 is not appropriate to the community, poses risk to residents and staff because R1 is refusing the medications, and the respite is ended as 8/30/2024. Executive Director stated R1’s responsible party was not provided a written notice and provided additional resources available during the phone call. CCL received no written notice of eviction for R1 and it was confirmed R1’s POA did not receive any written notice of the eviction. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility staff did not properly report abuse. The facility submitted a self-reported incident report for R1 and R2 for an incident that occurred on 8/28/2024 at approximately 4:45 pm. The SOC341 abuse reporting form states it was sent to the local Ombudsman office and CCL on 9/5/2024. Further investigation revealed it was not faxed to the local Ombudsman office until 9/7/2024 at 10:40 am, and CCL has no record of receiving this SOC341. Please continue to 809-C, Pg 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The facility could not provide proof that the SOC341 was submitted to CCL. This did not meet the 24-hour reporting timeframe requirement per AB 1417 and CCR 87211(c), and which are also listed in the instructions of the SOC341 form. Additionally, another SOC341 for an incident occurring on 8/31/2024 also was not sent to the Ombudsman office until 9/7/2024. CCL received the incident report for this incident via email at 9/7/2024 at 6:00 pm but no SOC341 was received by CCL. Based on the information obtained, the allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management visit to issue deficiencies discovered after reviewing incident reports. LPA met with Tyler Barnes, Administrator and explained the purpose of the visit. During the investigation, LPA Kontilis reviewed relevant documents and interviewed staff. LPA reviewed an incident report (IR) received 07/17/2024 that stated on 07/15/2024, Staff 1 (S1) failed to provide Resident 1 (R1) Morphine SO4 15mg tablet. R1’s physician was contacted on 07/17/2024 and R1 was placed on alert charting for 48 hours. The IR states med techs were provided medication training as a result of the medication error. An IR received on 07/19/2024 states on 06/30/2024, Staff 2 (S2) failed to provide medication to eleven residents in care. LPA requested physician’s orders for medications, Medication Administration Records (MARs) and staff schedules for June and July 2024. On 07/23/2024, LPA received a revised IR which provided additional information. The following medication errors were noted for 06/30/2024: -R2 did not receive their 8:00 pm: Senna 8.6 mg and Melatonin 5mg -R3 did not receive their 8:00 pm: Donepezil HCL 10mg and Mirtazapine 7.5mg -R4 did not receive their 5:00 pm: Biotrue Hydration Boost Eye Drops, Senna 8.6mg, Cephalexin 500mg -R5 did not receive their 8:00 pm: Ketorolac Tromethamine 0.5% Eye Drops, Timolol Maleate 0.5% Eye Drops, Quetiapine 25mg, Venlafaxine HCL ER 75mg -R6 did not receive 8:00 pm: Donepezil 10mg; Atorvastatin Calcium 20mg -R7 did not receive their 5:00 pm: Calcium 600-VitD3 600mg; 8:00 pm: Montelukast Sodium 10mg; Sertraline HCL 100mg; Donepezil HCL 5mg -R8 did not receive their 8:00 pm: Lorazepam 0.5mg, Quetiapine 25mg, Polyethylene Glycol 17mg -R9 did not receive their 5:00 pm: Memantine HCL 10mg, Acetaminophen 325mg, Preservision AREDS 250-90-40, Vitamin C 1,000mg; 8:00 pm: Donepezil 10mg, Melatonin 5mg Please continue to 809-C, Pg 2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 -R10 did not receive their 5:00 pm: Aspirin 81mg, Atorvastatin Calcium 40mg -R11 did not receive their 5:00 pm: Flecainide Acetate 100mg, Atorvastatin Calcium 20mg, Triamcinolone Acetonide 0.1% cream -R12 did not receive their 5:00 pm: Hydrocodone 5mg, Famotidine 20mg; 5:30 pm: Senna 8.6mg; 8:00 pm: Trazadone HCL 50mg The incident reports indicate resident’s physicians were contacted on 07/17/2024, after the discrepancies were discovered. Additionally, all affected residents were placed on alert charting for 48 hours after the discovery. The IR states S2 was terminated from the facility, and other med techs were to receive ongoing training to review policies and procedures for medications. LPA discussed the importance of accurate assistance with medication with the new Administrator. Additionally, on 08/28/2024, 08/29/2024, and 9/5/2024, LPA reviewed three incident reports for R13 that indicated R13 had multiple private caregivers. The private caregivers had fingerprint clearance but were not associated to the facility. Additionally, record review and interviews conducted revealed the facility contracts with an outside home health agency for additional staffing when needed as well as 1:1 for private care. Records reviewed revealed 10 temporary staff members had fingerprint clearance but were not associated to the facility. The following deficiencies were observed (See LIC 809-D.) and cited from the CA Code of Regulations, Title 22 Regulations. Civil penalty assessed for criminal record clearance transfer violation. Exit interview conducted. A copy of the report and civil penalties was issued at the time of the visit along with appeal rights.

This is an amended report. Santa Barbara Police Department (SBPD). Guerra stated he was unsure whether it was an officer from SBPD but was certain it was a representative from SBPD. Guerra further stated R1 was taken to the local hospital for evaluation. Record review revealed the hospital evaluation determined R1 sustained a skin tear and brain bleed as a result of the hospital evaluation. Medical records specify R1 sustained bilateral subdural hematomas. Guerra stated R1 did not return to the facility after R1's elopement. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that due to lack of supervision R1 eloped from the facility; therefore, the above allegation is deemed SUBSTANTIATED at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the CA Code of Regulations, Title 22 Regulations. A civil penalty of $500 is assessed due to R1 sustaining an injury as a result of a deficiency. Exit interview conducted. A copy of the report and civil penalty was issued at the time of the visit along with appeal rights. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 This is an amended report. During today’s visit, SRCD stated a Service Plan Meeting was scheduled on 9/16/2021 upon R1’s admission into the facility. Record review indicated R1’s Service Plan was updated on 9/29/2022 and 12/22/2022. SRCD further stated a Service Plan Meeting was scheduled to be held with R1’s responsible party on 2/14/2023. SRCD stated the Service Plan Meeting scheduled to be held on 2/14/2023 was to address changes of condition, emergency contact information, medication records, resident’s weight and current status, resident’s level of care and fall risk, interventions, latest Physician’s Report, Service Plan, and an open discussion regarding service and care. The Service Plan Meeting would include any/all hospitalizations, incidents, and elopements. SRCD stated he scheduled the Service Plan Meeting on or about 2/7/2023 and notified R1’s responsible party of the meeting prior to 2/7/2023. Based on interviews conducted and records reviewed, LPA determined that the facility updated R1’s service plan after residing in the facility for a year, and then following the third found on floor incident. Additionally, although the Service Plan Meeting on 2/14/2023 did not come to fruition due to R1 moving out of the facility, SRCD Guerra addressed the resident’s change of condition following one additional found of floor incident by scheduling the Service Plan Meeting with R1’s responsible party. Therefore, the allegation that staff did not address a resident’s change of condition is deemed Unsubstantiated at this time. Exit interview conducted. Report issued at the time of the visit.

On the allegation: Staff did not adequately manage resident's medication. It was alleged that from 6/29/2021 through 7/3/2021, R1 was given PRN medication but staff gave the PRN pre-emptively in anticipation of a behavioral issue (not per physician’s orders). Staff interviewed stated PRNs should not be given pre-emptively and staff should wait until the symptoms/behaviors specified on the PRN order are observed. Facility nurse confirmed they became aware on 7/6/2021 that a med tech gave PRNs inappropriately and on 7/7/2021 they counselled the med tech on the policy on PRNs. Facility nurse confirmed they did not have the problem reoccur after the counselling. Based on the information obtained, the allegation is deemed Substantiated at this time. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 in the first two weeks that R1 moved into the facility. R1’s responsible party also stated that R1 had “outbursts” and “you never knew they were going to happen, they just seem to happen.” Administrator recommended a psychiatric hospital for R1 due to their unusual and sporadic behaviors, or a one-on-one staff. Facility nurse stated they tried many different interventions with R1 including contacting R1’s physician and holding care conferences to discuss changing needs. R1 had a one-on-one staff after the need was identified. Based on the information obtained, R1’s behaviors were not due to a lack of supervision, and additional supervision was provided once the need was identified. Therefore the allegation is deemed Unsubstantiated at this time. On the allegation: Staff did not encourage resident's involvement in group activities while their one-on-one caregiver was present. It was alleged that when R1’s one-on-one private caregiver was present, staff would not involve R1 in group activities. Interview with R1’s visitor revealed that it appeared R1 got less attention from facility staff due to having a one-on-one caregiver present. Staff interviews revealed that all residents are encouraged to participate in activities, regardless of whether they have a one-on-one caregiver. Staff stated sometimes if residents are having behaviors or being disruptive, staff will redirect them and engage them one-on-one until the behaviors suppress. Staff stated even if they do not have a private one-of-one, sometimes an activity person works with them one-on-one. Staff stated they have an activities calendar posted and caregivers are assigned certain residents, which includes going to their rooms and encouraging them to participate in activities. Staff stated they do not encourage residents to be isolated in their rooms and encourage residents to participate every day. During visits to the facility, LPA observed residents participating in activities. Due to insufficient evidence to prove the allegation, the allegation is deemed Unsubstantiated at this time. On the allegation: Facility did not notify of Resident's change of condition. It was alleged that the facility notified R1’s doctor of incidents but did not notify R1’s responsible party. R1’s responsible party indicated the facility contacted R1’s physician to see if additional medications were appropriate, without first notifying the responsible party of the incident. R1’s responsible party learned of the incident from the physician contacting them. LPA reviewed incident reports for R1 dated 6/13/2021 and 6/17/2021, which both indicated R1’s responsible party was notified as well as physician and a care conference and medical evaluation would be scheduled. Both the responsible party and physician were contacted timely; therefore the allegation is deemed Unsubstantiated at this time. Please continue to 9099-C Pg 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On the allegation: Facility staff denied Resident visitation. It was alleged that staff encouraged R1’s visitors to not visit after R1 moved into the facility. Reporting party admitted this was a recommendation by staff in order to try to help R1 adjust to the facility. Visitor stated they followed facility’s recommendation. After R1 had a confrontation with another resident, the visitor was told to disregard the recommendation to not see R1 during the transition to make it easier. During an interview on 6/22/2021 with the Marketing Director, she stated transition is sometimes difficult for new residents. The Marketing Director stated they tell new residents their home is undergoing construction and tell the family members it may be beneficial to refrain from visiting the resident during the transition. LPA counseled the Marketing Director on the importance of accurately messaging the recommendation that residents may experience a better transition into the facility if visitors refrain from visiting and explained about residents’ personal rights. On 4/20/2022, the Marketing Director stated visitors have never been denied entry into the facility. The Marketing Director stated she recognized the need to change the messaging about the recommendation, and now emphasizes resident’s personal rights during the discussion. In an interview on 4/20/2022, Generations Program Director (GPD) confirmed they alert families/responsible parties as to how the residents are transitioning after moving into the facility. GPD stated if they observe a resident to be agitated after a visit or phone call, they will alert the family/responsible party. GPD confirmed they have never turned away a visitor and have made great efforts to allow for safe visitation during the COVID-19 pandemic. Based on the information obtained, the allegation is Unsubstantiated at this time. Technical Assistance was issued to the facility on 4/21/2022. On the allegation: Facility abandoned Resident. It was alleged that when R1 was in the hospital, the facility would not accept R1 back into the facility. Around the end of June 2021, R1’s responsible party received a phone call from corporate warning them that a 30-day eviction notice might be issued due to R1’s behaviors and increased level of care. On one occasion where R1 went to the hospital, and R1’s responsible party was told by hospital personnel R1 was not being allowed to return to the facility. As a result, R1 allegedly needed additional sedation to perform a COVID-19 test for another facility they might be transferred to. R1 was hospitalized for multiple days, and the facility stated they would accept R1 back to the facility once R1 was ready for discharge. R1’s responsible party confirmed an eviction notice was never issued. The facility did not refuse to accept R1 back once they were ready for discharge; therefore the allegation is Unsubstantiated at this time. LPA counselled Administrator about proper eviction notices and procedures. Exit interview conducted. Copy of report issued at the time of the visit.