Santa Barbara Memory Care.

and no diagnosis of dementia or mild cognitive impairment. All other residents in the facility have dementia or mild cognitive impairment. Interviews conducted revealed staff observed Resident 1 (R1) demonstrate inappropriate behavior towards other residents. Staff stated R1 was observed trying to go into other residents’ rooms and described R1’s behavior as “predatory”. Interviews conducted revealed R1 was observed with their hand between Resident 2’s (R2’s) legs and R1 “backed off” when R2 became combative towards R1. Interviews conducted revealed R1 was found “multiple times” with their hand on Resident 3’s (R3’s) breasts. Interviews conducted revealed Resident 4 (R4) demonstrated a different demeanor in R1’s presence and appeared to be “uncomfortable” when R1 was near R4. Interviews conducted revealed staff reported R1’s behavior and specific incidents to Administrator Gerr. Administrator responded saying the interactions are most likely consensual, especially between R1 and R4, and noted residents have personal rights. Staff stated they felt R1 followed and pursued R4, and coerced R4. The investigation revealed Administrator did not provide support or guidance to the staff and instead deflected the incidents by saying R1 had “their needs”. Staff indicated they were never directed to provide additional supervision to R1 or R4, despite the Administrator being aware of R1’s behaviors. Additionally, text messages and interviews revealed staff found R4 in R5’s room, with R4’s pants pulled down and the covers off of R5. Interviews revealed R4 was touching R5’s briefs. R5 was saying they did not need assistance, believing R4 to be a staff. R4 was very confused when staff intervened. Based on interviews conducted and records reviewed, the allegation Staff did not protect resident from being inappropriately touched by another resident is deemed Substantiated at this time. On the allegation, Staff does not provide a safe environment for resident: Reporting Party voiced concern for a resident’s safety when staff reported to Administrator that R1 was demonstrating inappropriate behavior towards other residents. Interviews conducted revealed R1 was observed trying to enter other residents’ rooms and when R1 was “called out” on their behavior, R1 would “slink off” and go to their room. Interviews conducted revealed when R1 “was affectionate” towards residents in the dining room, and when R1 was told “No” by staff, R1 would then leave the area and go to their room. Records review and interviews conducted revealed R1 has a diagnosis of neuropathy and no diagnosis of dementia or mild cognitive impairment. All other residents in the facility have dementia or mild cognitive impairment. By R1 residing in the facility, R1 is in an environment that is not compatible with their mental cognition and diagnosis. On 4/16/2025, LPA Kontilis conducted a Case Management visit to the facility wherein a citation was issued against the facility as a violation for admitting a resident who did not have a dementia diagnosis and did not require the level of care provided by the facility. The facility is a secured 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 perimeter memory care facility, per regulation, all residents must have conservatorship to be in a secured perimeter memory care facility or a signed acknowledgment that they agree to be in a secured perimeter facility. Based on the information obtained over the course of the investigation, R1 residing in a locked memory care facility with no dementia or mild cognitive impairment diagnosis and is/was residing in a facility that is not compatible with other residents in care, presents an unsafe and vulnerable environment detrimental to all residents including R1. Therefore, the allegation that Staff does not provide a safe environment for a resident is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report issued. Appeal Rights issued.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during the course of the investigation for Complaint Control #29-AS-20250310083615. LPA Kontilis met with Administrator Lisa Gerr and explained the purpose of the visit. During today’s visit, LPA addressed concerns that Administrator accepted Resident 1 (R1), a non-conserved individual who resided in the facility from 7/8/2024 to 4/27/2025. Records review and interviews conducted revealed R1 had a diagnosis of neuropathy and no diagnosis of dementia or mild cognitive impairment. Interviews conducted and records reviewed revealed R1 was not allowed visitors while residing in the facility and a sign was posted in the medication room by Administrator Gerr specifically naming R1’s family member with whom R1 co-habited prior to R1’s admission into the facility was not allowed to visit. Interviews conducted and records reviewed further revealed R1 was restricted to the confines of the locked facility and was not allowed to leave the facility upon their choice with or without R1’s family member. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report issued. Appeal Rights issued.

R1 stated the Administrator was in denial at first but many people knew what happened so they could not deny it anymore. R1 stated staff had gloves on and were taking the box out. LPA reviewed text messages between the Administrator and RP discussing the incident. The messages show RP stating they think the resident who pooped in the box may be the same one that came into R1’s room at night. LPA reviewed message from Administrator, that discusses the resident R1 was concerned about “who had been coming into [R1’s] room.” The message states the resident’s doctor has been contacted and they do not expect any more issues, and in the meantime staff will keep a close eye on the resident. On 01/15/2026 LPA Jeffries conducted an interview with Administrator who stated,On 01/15/2026 LPA Jeffries conducted an interview with Administrator, Lisa Gerr, who stated R2 did have observed elevated behaviors and were addressed by physician days after two incidents pertaining to this complaint. LPA Jeffries noted on prior visit to the facility on 05/21/2026 that facility was short on staff and was addressed in a case management visit report on 05/21/2026. Based on the information obtained, the allegation is Substantiated at this time. On the allegation: Due to lack of supervision, resident physically assaulted resident. It was alleged a resident came into R1’s room at night, ripped the blankets off R1 and grabbed R1’s arms. Staff interviewed stated there was an incident one night where Resident 2 (R2) wandered into R1’s room. Administrator stated R2 had experienced a change in demeanor, with wandering, going into other resident’s rooms, moving a shirt from room to room. Administrator stated they had informed R2’s physician and responsible parties, and watched R2 more closely with hourly checks. Administrator stated R2 had become more aggressive to R1. Administrator stated R1’s RP informed them a resident came into the room and “attacked” R1. Administrator stated they were no injuries, and they gave R1 a lock for their door. Administrator stated the same evening R2 gave unwanted advanced to a visitor, and the Administrator tried to redirect them, but R2 gave them an angry look. Administrator stated they had another appointment scheduled with R2’s physician on 5/6/2025 due to the increased behaviors. Administrator stated they offered R1 anything they needed to feel safe aside from the lock on the door. When interviewed, R1 stated a resident was ripping blankets out of their hand, and was grabbing them. R1 confirmed the Administrator got them a key for their door, but someone could come through the bathroom. R1 stated they were told R2 also went into another resident’s room and was standing over their bed staring at them. LPA reviewed text messages between the Administrator and RP discussing the incident. The messages show RP stating they think the resident who pooped in the box may be the same one that came into R1’s room at night. LPA reviewed message from Administrator, that discusses the resident R1 was concerned about “who had been coming into [R1’s] room.” The message states the resident’s doctor has been contacted and they do not expect any more issues, and in the meantime staff will keep a close eye on the resident. Based on the information obtained, the allegation is Substantiated at this time. 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 Administrator gave their next available time at the facility. During interviews, R1 indicated they believed the Administrator was “brainwashing” them to turn against their RP. R1 also stated they had panic attacks. R1 stated they had just had a medical treatment that takes a toll on them, and then Administrator explained aspects of the lease or admission agreement. When R1 put on glasses and read the documents, they were different and they felt the Administrator had “lied.” R1 stated the Administrator made them upset and they ended up in the hospital with atrial fibrillation. R1 was unable to be interviewed any further. RP stated although R1 did not have dementia, they felt R1’s medical treatments were affecting some parts of R1’s memory. Staff interviewed confirmed R1 had memory issues, and in the staff’s opinion, was confused, very anxious, could get “rattled.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. The Administrator is reminded to conduct themselves in an appropriate manner at all times that ensures residents are treated with respect. Exit interview conducted. Copy of report issued at the time of the visit.

Communication was poor at best.” On 06/25/2025 LPA reviewed documentation provided by F1 that included a single email correspondence by email dated Tuesday January 30th, 2024 @ 8:00pm with Business Office Manager of Facility, Staff 1 (S1), acknowledging there was need to solve “billing issues”. LPA also reviewed documentation of billing statements for the 30 months that R1 resided in the facility. LPA noted that late fees of $100 and $250 began to appear on R1’s billing statement on 04/15/2022 which showed 8 late charges of $100 and starting 06/15/2025 there were 14 late charges of $250 beginning on 06/15/2023. Two of those late charges of $250 were refunded, the first refund was 07/15/2025, and the second was 08/15/2025, both charges were refunded the same day they were billed according to F1’s billing statement. In February of 2024, F1’s bank statement indicated alternative payment method to Rent Café’, From February 2024 through July 2024 all payments were assessed a late fee of $250. Based on the email dated 01/30/2024. Late charge totals from 04/15/2022 through 05/15/2023 of $100 totaled $800 in accessed late fees. From 06/15/2023 through 07/13/2024 there were 14 late fee charges of $250, with 2 late fee charges of $250 refunded ($500) accounting for a total of $3000 ($3500) in accessed late fees at $250. For the 30 months R1 resided in the facility there was a total late fee charge of $3800 ($4300) noted to R1’s billing statement. The email from S1 to F1 dated 01/30/2025 indicates there are billing issues accounts for a total of $2300 in late fee charges up to that date. LPA noted that facility Contact pertaining to payments reads as follows, “The Monthly Fee is payable in advance by the first (1st) day of each calendar month and is considered delinquent of not received by the fifth (5th) day of the month." Based on check book log provided by F1 which shows dates posted on checks are prior to due date and interview indicating checks were place in the mail before due date and followed up with phone calls for confirmation that checks sent by mail had been received, with no facility staff currently employed that handled mail payments available to support to the contrary. On 02/24/2025, and 05/21/2025 LPA interviewed current facility Administrator Lisa Gerr, who stated they did not have knowledge of specific billing issues prior to being an administrator. LPA reviewed billing documentation of 16 additional residents all residing at the facility during the same time period. All 16 residents resided approximately one month or less compared to R1’s 30 months as a resident, with 3 out of 16 receiving late fee charges with less than one month of being a resident at this facility. LPA attempted to contact former Business Office Manager (S1) who sent the “resolve billing issues” email but received no response. LPA noted that R1’s billing statement indicated a refund of $756.46 which notes there is a potential overbilling discrepancy of $3,043.54. At this time based on documentation and interviews, there is enough evidence support the allegation of, “Facility did not issue a refund to resident.” and is substantiated at this time. Exit interview, report read, citation issued, appeal rights and report provided.

W1 stated that they contacted Administrator Lisa Gerr who stated that the medication Olanzapine was not delivered to her facility until after R1's discharge on 05/01/25. W1 stated that they have receipt from Federal Drug Company that shows all medications were delivered to the facility on 04/22/25. W1 stated that the missing medication was eventually provided to R1's new facility Administrator on 05/19/2025. On 06/25/25 LPA Jeffries conducted an interview with Administrator Lisa Gerr, who stated, "..on (05/01/2025) R1 returned to the facility after normal business hours requesting all medications for 1 week. Administrator provided all medications from R1's medication storage bin with custody receipt provided and singed. Administrator stated that medication in question was placed in S1 desk drawer and was discovered at unknown later date and was delivered to new facility with custody receipt 05/19/25.On 06/24/25, LPA reviewed documentation from Federal Drug Company, Drug Order Delivery Form, which indicated that a total of 6 medications, including (Olanzapine 2.5mg, Quantity 30) were delivered to this facility on 04/22/25, singed and dated by facility Staff 1 (S1). This delivery form establishes the custody of R1's medications were in the care of this facility starting on 04/22/25. On 05/01/25 all other medications, with the exception of Olanzapine 2.5mg, were provided to W1 by the Administrator, Lisa Gerr, due to R1 permenatly leaving as a resident on the evening of 05/01/25. On 06/25/25, LPA Jeffries received an email from Robert Glock, Administrator of Rt 1's current facility stating that on 05/19/25 Lisa Gerr dropped of R1's personal items that included the Olanzapine 2.5mg medication. Due to the facility having documented custody of the Olanzapine medication on 04/22/25, and on 05/01/25 Administrator, Lisa Gerr provided W1 with R1s medications, excluding the Olanzapine, Based on documentation, and interviews, there is enough evidence to support the allegation of, "Staff are mismanaging residents medications." and is substantiated at this time. Exit interview, report read, citation issued, appeal rights and report provided.

At 11:20pm on 05/21/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to continue the investigation to a subsequent complaint. LPA met with, Administrator, Lisa Gerr announced who he is and the reason for the visit. LPA conducted a cursory tour of the facility. LPA conducted interviews with staff and attempted interviews with residents, and reviewed documentation. It was discovered that Direct Care Staff 1 (S1) had not been registered with Guardian and was not present on Licensing Information Systems (LIS) when checked during the complaint investigation visit. Administrator stated that S1 was cleared and associated, however it S1 did not appear on both background clearance cites. LPA assisted Administrator to attain S1's PERS number as was able to associate S1 during the course of the visit. Administrator stated that this was S1's first day. This resulted in a citation of S1 not being cleared for 1 day (87355(a)). During the complaint visit LPA requested Registry of Residents. Administrator stated the f acility did not have a Register of Residents (LIC9020) upon demand during normal business hours resulting a citation issued (87508(b)). Administrator was able to create a new LIC9020 during the course of the visit. LPA issued two citations and a civil penalty as a result of this subsequent case management visit to the complaint report issued on the same day and visit. Exit interview, report read, citations and civil penalty issued, appeal rights and report provided.

LPA Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20250310083615 investigation visit conducted on 4/16/2025. The Case Management visit is being conducted to address CCLD’s concern that the Licensee accepted Resident 1 (R1), a non-conserved individual who currently resides in the locked memory care facility. Record review and interviews conducted revealed R1 does not have a dementia diagnosis and resident does not require the level of care provided by this facility. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report issued. Appeal Rights issued.

This Case Management visit was conducted to address deficiencies noted during Complaint Control #29-AS-20250310083615 investigation visit conducted on 3/19/2025. The Case Management visit is being conducted to discuss the reporting of a death requirement as per regulation 87211(a)(1)(A) Reporting Requirements. During today’s visit, documents reviewed revealed on 3/11/2025 CCLD received LIC624A stating on 3/3/2025 Resident 1 (R1) passed away due to “metabolic encephalopathy and adult failure to thrive”. Administrator Gerr stated R1 was not on hospice and not reporting it within the seven day requirement was “an oversight”. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report issued at the time of the visit.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required Inspection of the facility. At the time of arrival, there were fourteen (14) residents in care and two staff, Business Office Manager, and Administrator Lisa Gerr on duty. LPA met with Lisa Gerr, Administrator and explained the purpose of the visit. Entrance interview conducted: The facility is a one-story Residential Care Facility for the Elderly (RCFE) with a capacity of thirty-six (36) residents. The facility is a memory care facility for residents with a dementia diagnosis. The facility has a fire clearance for thirty-six (36) non-ambulatory residents of which thirty-six (36) can be bedridden and has a hospice waiver for ten (10) residents. Currently, there are two (2) residents on hospice and no bedridden residents residing in the facility. LPA and BOD toured the facility to assess the physical environment and accommodations. The following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. Upon entry, there is a gate that requires a code to enter the premises and a phone number posted to the facility for those who do not have a code. Entering through the gate, is a large walkway and driveway leading up to a large front patio with seating areas including patio chairs, tables with umbrellas, couches, and mini-couches. Entering past the patio area, the administrator’s office is located on the west side of the building. Staff files and other confidential information is kept in the administrator’s office. Entering into the main area of the facility is the dining area/common area on the east side of the room. Socializing, meals, and activities are held in the dining/common area. 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 The kitchen is located at the back of the dining/common area and is inaccessible to residents in care. LPA observed seven (7) days of non-perishable food items and two (2) days of perishable food items. LPA observed approximately 16 heads of iceberg lettuce loosely in a box without proper packaging and date stamped. LPA reviewed Resident 1's (R1's) hospice file and determined no hospice notification has been submitted to CCLD within five (5) business of having been placed on hospice. At approximately 3:19 pm, LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster. Record review revealed Staff 1 (S1) has worked in the facility since 8/23/2024 and has not been properly associated to the facility prior to employment; Staff 2 (S2) has worked in the facility since 11/1/2024 and has not been properly associated to the facility; and, Staff 3 (S3) who was hired on or about 10/16/2024 has not been properly associated to the facility. Due to time restraints, LPA will return at a later date to continue the annual inspection. The following deficiencies were observed (See LIC 809-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. Due to technical difficulties, copy of report and Appeal Rights issued via email.

During the visit, the LPA conducted a physical tour of the facility and requested and obtained documents pertinent to the investigation. The Administrator at the time was notified that the complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Jose Santana for further investigation. Investigator Santana conducted interviews on 07/06/2022, at approximately 4:00pm, with R1’s resident representative; on 07/12/2022, from approximately 1:05pm to 3:30pm, with facility staff; on 07/13/2022, from approximately 7:00am to 3:30pm, with facility staff, Memory Care Director and former facility Executive Director; on 07/18/2022, at approximately 11:00am, with Memory Care Director; on 08/02/2022, at approximately 5:05pm, with Cottage Hospital attending physician; on 08/05/2022, at approximately 6:50pm, with Cottage Hospital attending physician; on 08/09/2022, at approximately 3:40pm, with R1’s resident representative; on 08/23/2022, at approximately 10:25am, with Central Coast Home Health Services (CCHS) and on 08/24/2002, at approximately 10:30am, attempted interview with R1’s Primary Care Physician (PCP). Additionally, Investigator Santana obtained and reviewed copies of R1’s facility file documents, hospital records and home health records. On 12/24/2020, at 3:46pm, R1 arrived at Santa Barbara Cottage Hospital (SBCH) via ambulance for a sudden onset of difficulty in breathing, according to the Skilled Nursing Facility where R1 was residing. While at the hospital, R1 was diagnosed with COVID-19, anasarca, hypoalbuminemia, hypokalemia, among other conditions. R1’s sepsis screen showed a suspected infection, and a urinalysis showed an abnormal result. R1 had also previously had sepsis on 09/17/2020. R1 had a history of diabetes mellitus, high cholesterol, and hypertension, along with atrial fibrillation, gastritis, hiatal hernia with GERD, cholelithiasis, Schatzki’s ring, and prior alcohol abuse with liver disease. Continued on 9099-C 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 01/01/2021, SBCH attempted to locate skilled nursing facilities that would accept R1. The hospital records also noted physical therapy was attempted with R1, but R1 declined to participate, saying they were “too tired”. On 01/04/2021, R1 was diagnosed by the hospital registered dietician (RD) who noted R1’s malnutrition was likely related to multiple chronic medical issues as evidenced by weakness, prior weight loss, and ongoing inadequate oral intake; R1’s nutrition risk level was moderate. R1’s blood glucose was being controlled with R1’s current insulin regimen and carb-controlled diet. The RD suspected R1’s appetite would improve as acute issues improved and R1 was in a more comfortable environment. On 01/05/2021, the attending physician noted that R1’s prognosis had been full recovery back to baseline of underlying dementia. On 01/06/2021, the case manager informed R1’s resident representative that no skilled nursing facilities were accepting residents in the area. R1’s resident representative advised that they were considering placement at the Pacifica Senior Living facility. The facility administrator agreed to admit R1 the following day on 01/07/2021. R1 was discharged from the hospital on 01/07/2021 at 3:41pm. A review of the Physician Report, dated 01/07/2021, completed by the SBCH attending physician, noted R1’s primary diagnosis as anasarca, with secondary diagnoses of atrial fibrillation, anemia, GERD, and cirrhosis. The accompanying medication standing orders listed only over-the-counter medications to be taken as needed. The Pre-Placement Appraisal, dated 01/07/2021, also completed by the same SBCH physician noted that R1 had the following conditions and listed the medications that R1 was prescribed at that time: Aspirin for atrial fibrillation, Bumex for HFPEF and anasarca, Lactulose for cirrhosis, Protonix for GERD, Folic Acid for anemia, and Levemir and sliding scale Aspart for diabetes. An administrator for CCHHS stated sometimes hospital discharge records list all medications given to patients in the hospital, which are not necessarily meant to continue taking upon discharge. CCHHS personnel stated they did not have a list of medication from the hospital that says what medications R1 was to take upon discharge. CCHHS paperwork states per Cottage Health, “you have not been prescribed any medications.” Continued on 9099-C 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 However, upon further investigation CCL located a medication discharge list on the Interfacility Transfer After Visit Summary from Cottage Hospital, that neither the facility nor CCHHS had in their possession. The Interfacility Transfer Medications included Bumex to be given twice daily from 01/07/2021 at 9:00pm until discontinued, insulin aspart pen injection 0-10 units to be given on a sliding scale four times daily and nightly from 01/07/2021 at 12:00pm until discontinued, and insulin determir pen injection 15 units to be given daily from 01/08/2021 at 9:00am until discontinued, among other medications. On 01/13/2021, CCHHS completed their initial assessment of R1. R1’s primary diagnosis was COVID-19 acute respiratory disease, but other diagnoses included type 2 diabetes mellitus without complications, hypertension, and hyperlipidemia. R1 was noted as being diabetic without insulin dependence. R1 was also noted as not taking any medication with the exception of over-the-counter and herbal medications. CCHHS had orders for skilled nursing, physical therapy, and occupational therapy. There were also orders for social work because R1’s resident representative was concerned that R1 was not prescribed the correct medications at the facility. The facility reported R1 was consuming smoothies alone, so CCHHS ordered a nutrition evaluation because of R1’s decreased appetite and weight loss. The facility reported R1 was only eating twice a day. R1’s physician orders called for a low carb diet with no concentrated sweets. During the skilled nursing visits on 01/13/2021, 01/20/2021, 01/26/2021 and 01/27/2021, staff reported to the nurse that R1 had bowels movements on those dates. Physical therapy was attempted with R1 on 01/15/2021 and 01/20/2021, but R1 resisted and refused. On 01/21/2021, R1 was assigned a new PCP and had a tele-health visit with R1’s resident representative to review R1’s recent hospitalization, recent events, as well as past medical history and goals of care. PCP was aware that R1 was “apparently not receiving any medication as listed on the physician’s report”. Following the tele-health visit, PCP ordered a speech therapy consult and an order for an RN to check R1’s vitals and to report R1’s blood glucose. On 01/28/2021, PCP ordered for CCHHS to call R1’s family member “to assist with lab draw if patient uncooperative”, and prescribed Bumex along with over-the-counter medications. Continued on 9099-C 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 02/01/2021, staff found R1 on the floor in their bedroom. R1 was assessed for injuries and 911 was called due to R1 complaining of pain. Emergency Medical Services (EMS) arrived at 3:57pm and transported R1 to SBCH. R1 was hospitalized at SBCH for evaluation of bruising and swelling to the left upper chest. Chief complaints were abrasions as a result of the fall out of a wheelchair. Medics reported a blood glucose of 499. Per hospital records, skin tears and ecchymosis were noted to bilateral forearms. Medics also reported R1 does not take any prescription medications. R1’s diagnoses included sepsis due to a urinary tract infection (UTI), hematoma of the left chest wall, acute retention of urine, and stage 3 chronic kidney disease, among other conditions. A CT scan was taken of chest, abdomen, and pelvis showed a large anterior left chest wall hematoma without associated fracture, moderate stool burden throughout the colon correlates for constipation and predominately sub-diaphragmatic/perihepatic ascites on the right, which was new compared to the previous study and is of unknown etiology. R1 had clinical signs for dehydration that included dry mucous membranes, tachycardia, and abnormal vital signs. R1 required a large volume of rapid fluid resuscitation through IV. R1 had urinary retention that was alleviated when a Foley catheter was inserted and drained greater than 1500 cc of urine. This was consistent with an infection and was confirmed by R1 having an elevated white blood count, procalcitonin, and lactate levels. Antibiotics and fluids were ordered along with 10 units of insulin. On 02/02/2021, R1 was discharged to home and placed on hospice. The medical records reviewed indicate that R1’s sepsis resulted from a UTI. The SBCH treating physician advised that R1’s sepsis was caused by a UTI that may have been caused in part by effects of unmanaged diabetes. The facility failed to notice R1’s diabetes diagnosis, which was clearly listed on R1’s pre-placement appraisal at the time of admission to the facility on 01/07/2021. The former facility administrator stated that R1 had no prescriptions at the time of admission, but had the facility known that R1 required insulin, as is indicated on the pre-placement appraisal, the facility would not have admitted R1 without home health in place for a nurse to administer it. Continued on 9099-C 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 It was clear from the 01/07/2021 hospital discharge documentation that the attending physician intended for R1 to have regular labs, and these recommendations were sent to CCHH at the time of hospital discharge. For reasons unknown, home health did not initiate home health services until 01/13/2021, which was nearly a wee

However, the residents’ pre-admission fees were not refunded despite never moving in and not signing an admission agreement. Residents’ responsible party indicated they contacted the facility in May 2022, and communicated with Administrator Miriam Santiago and Regional Director Brittnee Kreymer-Austin. They were informed the facility had two rooms available, but insisted they needed to apply immediately, including paying a community fee and base cost as of May 31, 2022. Responsible party paid by credit card to hold the rooms and received the receipt by email. Resident 1 (R1) paid $3776.10 on 5/13/22 and Resident 2 (R2) paid $1726.10 on 5/12/22. The two residents never moved in, and one passed away in June 2022. Responsible party contacted Administrator and Regional Director by phone and email to state the remaining resident would not move in. Responsible party stated the June 2022 fees were abated and they were released from the rooms July going forward; however, the community (pre-admission) fee was never refunded. Administrator Santiago was interviewed on 6/29/23. Administrator indicated she personally did not take the payment for the pre-admission fee. She stated she would request they send out a refund. On 5/30/2024, facility manager confirmed the community fees for R1 and R2 should have been refunded, but they were not. Facility manager was working with their accounting department to get the refund issued. Based on the information obtained, the allegation Facility did not give a refund to a prospective residents after deciding not to move in is Substantiated at this time. Exit interview conducted, deficiency cited on 9099-D, copy of report given, appeal rights given.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required Inspection of the facility. At the time of arrival, there were two (2) staff on duty and fourteen (14) residents in care. LPA met with Cynthia Garcia, Business Office Director (BOD), and explained the purpose of the visit. Entrance interview conducted: The facility is a one-story Residential Care Facility for the Elderly (RCFE) with a capacity of thirty-six (36) residents. The facility is a memory care facility for residents with a dementia diagnosis. The facility has a fire clearance for thirty-six (36) bedridden residents and a hospice waiver for ten (10) residents. Currently, there are no residents on hospice and no bedridden residents residing in the facility. LPA and BOD toured the facility to assess the physical environment and accommodations. The following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. Upon entry, there is a gate that requires a code to enter the premises and a phone number posted to the facility for those who do not have a code. Entering through the gate, is a large walkway and driveway leading up to a large front patio with seating areas including patio chairs, tables with umbrellas, couches, and mini-couches. Entering past the patio area, the administrator’s office is located on the west side of the building. Staff files and other confidential information is kept in the administrator’s office. Entering into the main area of the facility is the dining area/common area on the east side of the room. Socializing, meals, and activities are held in the dining/common area. The kitchen is located at the back of the dining/common area and is inaccessible to residents in care. LPA observed seven (7) days of non-perishable food items and two (2) days of perishable food items. LPA also observed an ample amount of emergency and frozen foods. The medication room is located on the west side of the facility just past the main entry. The medication room requires a code to enter the room. Residents’ medications, residents’ files, and first aid kit are kept in the medication room. The medication room overlooks the common area. < 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 Past the medication room is a hallway that leads to residents’ rooms, bathrooms, and shower rooms. There are twenty-four bedrooms and three (3) full showers located off the hallways. Each bedroom is equipped with a sink in the bedroom and a toilet room. The bedrooms were inspected and found to have sufficient bedding, lighting, and storage for each resident in care. Each room has individual temperature control to be adjusted to the resident's comfort level. The three shower rooms are set up for residents to be taken into the shower room for showers while staying in their wheelchair. The shower rooms have non-slip flooring and grab bars for the residents and there are shower chairs the residents can utilize. The Facility maintains five (5) working carbon monoxide detectors and approximately eight (8) smoke detectors all in good working order. From approximately 2:55 pm to 3:05 pm, LPA and BOD observed foul odors in the bathrooms of Bedrooms 4 and 5 and the Bedrooms 9 and 16. From approximately 3:15 pm to 3:17 pm, LPA and BOD observed five fire extinguishers were last serviced on 1/5/2023. Due to time restraints, LPA will return at a later date to continue the annual inspection. Exit interview conducted. The following deficiencies were observed (see LIC809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil penalty issued at the time of the visit. Failure to correct the deficiencies by the correction due date may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.

During today’s visit, interviews conducted revealed that staff are sometimes unable to answer the phone because they are assisting residents with brief changes, showers, medication distribution, and other basic services. Staff 1 (S1) stated when the calls go to voicemail, the staff (caregivers, medication technicians, etc) on duty do not have access to retrieve the voicemail messages. S1 further stated when S1 takes a call and cannot provide information, the caller’s name and phone number are taken in a message book then S1 gives it to a “corporate person” when they come to the facility. During today’s visit, LPA observed the Business Office Director and the Regional Director of Operations were not available at the facility. Staff stated the Business Office Director was at the facility for approximately three hours on Monday, 1/22/2024. Staff further stated the Regional Director of Operations was at the facility for approximately one hour one day last week, possibly Tuesday, 1/16/2024 or Wednesday, 1/17/2024. Based on interviews conducted, records reviewed, and observations made, the allegation that due to lack of staffing, the facility staff are not answering the facility telephone is Substantiated at this time. On the allegation, staff did not notify authorized representative of an incident with a resident, Reporting Party (RP) stated RP learned that Resident 1 (R1) was taken to the hospital emergency room on 12/4/2023 when RP received an invoice from the medical emergency agency about three weeks after the emergency transport. During today’s visit, LPA obtained medical discharge papers and care notes indicating R1 was sent to the hospital via a call to 9-1-1. At approximately 2:34 pm, Staff 2 (S2) stated on 12/4/2023, R1 was sent to the hospital emergency room the evening of 12/4/2023. S2 further stated R1 returned from the hospital emergency room that same evening. LPA reviewed LIC624 Serious Illness/Serious Injury Reports submitted by the facility to Community Care Licensing Division (CCLD) and determined that CCLD did not receive LIC624, Serious Illness/Injury Report notifying CCLD of R1’s hospital visit. At the time of the visit, no record of an incident report was available reporting R1’s emergency room visit to R1’s responsible parties or to CCLD. Based on interviews conducted and records reviewed, the allegation that facility staff did not notify an authorized representative of an incident with a resident is 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 issued at the time of the visit.

between Administrator Santiago, Pacifica Senior Living Santa Barbara and/or Licensee, Pacific Coast Senior Living Management, LLC corporate associates. At the time of the visit, LPA obtained documents pertaining to the allegation. At the time of the visit, Administrator stated an accounting is still being completed by Administrator Santiago. Administrator stated there appears to be errors in R1's accounting ledger and the accounting reconciliation should be completed by 6/15/2023. Administrator stated she received an email from R1’s RP, however has not yet responded to it. Based on interviews conducted and records reviewed, LPA determined that the Licensee should have issued a refund within fifteen (15) days after R1’s belongings were removed from the facility; therefore, the allegation that facility staff did not issue a timely refund in the event of a resident’s death is Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC9099-D). Exit interview conducted. Citation issued. Copy of report and Appeal Rights issued at the time of the visit.

On 3/17/2023, RP informed Administrator Santiago that PR1 would not be moving into the facility. Administrator stated to RP that a refund would be issued for $2,500 and $500 would be withheld to cover the costs of a preassessment conducted by Administrator Santiago which was conducted on 3/8/2023 in PR1 and RP’s private home. Records reviewed revealed RP attempted contact inquiring about the issuance of the refund with Administrator Santiago on 4/25/2023, 5/7/2023, 5/9/2023, 5/17/2023, 5/21/2023, and 5/22/2023. Administrator Santiago confirmed contacts by RP on 5/9/2023, 5/17/2023, and 5/22/2023. Records reviewed revealed an email exchange between Administrator Santiago, Sanket Patel, Corporate Associate, Accounting Dept, Pacifica Senior Living, and Tonya Crawford, Accounts Receivable Manager, Pacifica Senior Living discussing RP’s refund. On 5/25/2023, Administrator Santiago confirmed to Pacifica Senior Living corporate representatives that a preassessment was conducted and the refund amount should be $2,500. During today’s visit at approximately 3:16 pm, Administrator Santiago stated she has not received a response from the corporate office regarding RP’s deposit. Based on the interviews conducted and records reviewed, LPA determined that the Licensee should have issued a refund in the amount of $2,500 on 4/1/2023 based on the information that RP informed Administrator Santiago on 3/17/2023 that PR1 would not be moving into the facility. Moreover, based on the Refundable Community Fee Agreement dated 3/17/2023, the Licensee should have issued the $2,500 refund to RP no later than 5/11/2023—fifteen (15) days after the cancellation of the apartment hold on 4/16/2023. Therefore, the allegation that facility did not give a prospective resident a refund of the deposit paid after deciding not to move in is Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC9099-D). Exit interview conducted. Citation issued. Due to technical difficulties, copy of report and Appeal Rights were issued via email after signatures were obtained.