Westmont of Santa Barbara

(a)... (25)To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154. This requirement was not met as evidenced by: Based on interview Licensee did not comply with the regulation above, R1’s package was not found after carrier delivered to the facility which possess a potential personal rights risk to residents in care.

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9)To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidenced by: Based on staff turnover and interviews the Licensee did not comply with the regulation above, residents responsible parties did not get responses from Administrator/Licensee which posses a potential health, safety and personal rights risk to residents in care.

(f)...one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities,...staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities....,This requirement was not met as evidenced by: Based on staff and resident interviews, the Activity Director quit, and it took several months to fill the position, activities were not being conducted as the calendar indicated which poses a potential health, safety and personal rights risk to residents in care.

(a)…(3)…(C)Clean linen, including... The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times...The requirement was not met as evidenced by: Based on LPA observation and interviews, the Licensee did not comply with the regulation above, R1’s linens were not being changed more often to ensure R1 had clean linen to always use which possess a potential health, safety and person rights risk to residents in care.

(b)... (3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by: Based on LPA observation and interviews the Licensee did not comply with the regulations above, R1’s room was not kept clean and free from odors from incontinence which possess a potential health, safety and personal rights risk to residents in care.

(a)... (4)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 was not met as evidenced by: Based on interviews and records the Licensee did not comply with the regulation above, Residents that pushed call buttons for care needs waited prolonged periods of time for assistance which possess a potential health, safety and personal rights risk to residents in care.

(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...Additional staff shall be employed as necessary to perform..., cooking, house cleaning, laundering, and maintenance...This requirement was not met as evidenced by: Based on interviews and records the License did not comply with the regulation above due to insufficient staffing did not perform timely care, activities, food service and housekeeping to residents in care which possess a potential health & safety risk to residents in care.

...residents are regularly observed for changes in physical,...social ...functioning...assistance is provided...observation reveals unmet needs.... attention of the resident's physician and the resident's person responsible,... This requirement was not met as evidenced by: Based on interview and record review the Licensee did not comply with the regulation above Staff did not report to R1’s RP several dates and incidents that were faxed to the physician which possess a potential health, safety and personal rights risk to residents in care.

(a) ...increases the rates of fees for residents or makes increases in any of its rate structures for services,...90 days’ prior written notice to the residents or the residents’ representatives...amount of the increase and the reason or reasons for the increase,,...This requirement was not met as evidenced by: Based on interview and record review the Licensee did not comply with the H&S code above. Facility mailed out notices, not all notives were received by the RP’s and some notices were not a full 60days notice which possess a potential health, safety and personal rights risk to residents in care.

(i)When there is significant change in condition,...or once every 12 months,...the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's rep,... facility staff,...,Resident Participation.... This requirement was not met as evidenced by: Based on records and interviews the licensee did not comply with the regulation above Staff conducted a reappraisal Service Plan and did not make contact with R1’s RP to go over or have a meeting to discuss, letting R1 sign and putting the new fees in effect which poses a potential health, safety and personal rights risk to residents in care.

(a)...(1)...(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: Based on incident reporting the Licensee did not comply with the regulation above The facility did not report any medication errors or discrepancies for R1 which possess a potential Health, safety and personal rights risk to residents in care.

(a)...(4)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 was not met as evidenced by: Based on interviews and records the Licensee did not comply with the regulation above, staff were not competent in handling the centrally stored medications and assistance to residents, without errors which possess a potential health, safety and personal rights risk to residents in care.

(a)...:(1)...the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training,...and 8 hours of other training or instruction,...which shall be completed within the first four weeks of employment. This requirement was not met as evidenced by: Based on record review the Licensee did not comply with the regulation above staff did not take initial /or annual medication training which possess a potential health, safety and personal rights risk to residents in care.

87506(c) Residents Records: (c) All information and records obtained from or regarding residents shall be confidential.This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as a confidential document of one resident was found in another resident's record which poses a potential safety and personal rights risk to residents in care.

Based on observation and record review, the licensee did not comply with the section cited above when R1 was administered Hydromorphone 2mg on 6/15/2025 at 5:50 am by one staff member and again at 6:00 am by another staff member which poses an immediate health and safety risk to residents in care.

87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times…This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as the carpet in a resident’s room was observed to be stained and soiled which poses/posed a potential health, safety, or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited when residents did not receive their medication as prescribed, which posed an immediate health and safety risk to residents in care.

Based on record review and interview, the licensee did not comply with the section cited above when a Pre-Appraisal was not conducted for Resident 10 (R10) prior to admission into the facility on or before 3/27/2023 which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review and observation, the licensee did not comply with the section cited above as staff trainings do not include a minimum of four hours per year of training in postural support, restricted health conditions, and hospice care which poses an immediate health, safety or personal rights risk to persons in care..

Based on record review, the licensee did not comply with the section cited above as previous Administrator was no longer employed on or about May 10, 2024; Licensee has not provided information to CCLD to name the previous Interim Administrator and/or current Acting Executive Director as Facility Administrator which poses a potential health and safety risk to residents in care.

Based on observation and interview conducted, the licensee did not comply with the section cited above when the outside patio areas between Assisted Living and Memory Care were observed to be unclean and not sanitary due to birds nesting in the area.

Based on interview and record review, the licensee did not comply with the section cited when Resident 1’s IR1’s) Centrally Stored Medication Record did not list two prescribed medications.

87466 Observation of the Resident. When changes…are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when R1’s missed medications were not communicated to their physician, which posed an immediate health and safety risk to residents in care.

87465 Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when multiple residents did not receive their medication as prescribed, which posed an immediate health and safety risk to residents in care.

87211 Reporting Requirements. A written report shall be submitted to the licensing agency…Any incident which threatens the welfare, safety, or health of any resident…This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above when they failed to report a bus accident involving residents and medication errors, which posed a potential health and safety risk to residents in care.

87218(a)(2) Theft and Loss: A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. This requirement was not met as evidenced by: Based on interview, the licensee did not comply with the section cited above, as they were unable to properly safeguard resident property, which poses a potential personal rights risk to residents in care.

87465(a)(2) Incidental and Medical Care: A plan for incidental medical and dental care shall be developed by each facility. The licensee shall provide assistance in meeting necessary medical and dental needs.This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when not asking for R1’s refills timely, which posed an immediate health and safety risk to residents in care.

87468.2(a)(19) Personal Rights. To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days…This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above when they did not provide R1’s responsible party access to all of R1’s records, which posed a potential personal rights risk to residents in care.

87411(a) Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Additional staff shall be employed as necessary to perform…cooking… This requirement was not met as evidenced by:Based on interviews, the licensee did not comply with the section cited when they did not employ sufficient dining staff, which posted a potential health and safety risk to residents in care.

87411(c) Personnel Requirements. All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625…This requirement was not met as evidenced by: Based on record reviews, the licensee did not comply with the section cited above when staff did not have adequate training in 2022, which posed a potential health and safety risk to residents in care.

87303(i) Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria…This requirement was not met as evidenced by: Based on records review, the licensee did not comply with the section cited above when staff did not answer calls timely, which posed a potential health and safety risk to residents in care.

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.This requirement was not met as evidenced by: Based on interview and observation, the licensee did not comply with the section cited above when the facility had a mal odor and feces on R1’s wall, which posed a potential health risk to residents in care.

87211(a)(1) Reporting requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when they did not notify R1’s RP of a fall in writing, which posed a potential health, safety and personal rights risk to residents in care.

Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2.This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when they failed to respond to R1’s call button for assistance, which posed an immediate health and safety risk to residents in care.

87468.1(a)(1) Personal Rights. Residents…have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when staff spoke inappropriately to residents, which posed a potential personal rights risk to residents in care.

Based on observation and record review, the licensee did not comply with the section cited above when a medication inventory revealed out of 24 medications reviewed, 7 medications were not administered per Doctor's orders which poses an immediate health, safety or personal rights risk to persons in care.

87506(c) Resident Records: All information and records obtained from or regarding residents shall be confidential.This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above as Residents' records were exposed when the Resident Service Director office door was observed to be fully open which poses an immediate health and safety risk to residents in care.

87355(e)(2) Criminal Record Clearance. (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as prior to being present and/or working in the facility, one staff member was not associated to the facility which poses an immediate health and safety risk to residents in care.

87468.1(a)(2) Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Based on LPA observation, Licensee failed to ensure all staff wore face coverings properly at all times while in the facilities. Staff 1, Staff 2, Staff, 3, Staff 4 were not wearing a mask at the time LPA conducted a tour of the facility which poses an immediate health, safety and personal rights risk to residents in care.

87355(e)(2) Criminal Record Clearance. (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as prior to being present and/or working in the facility, 18 home care agency staff, 3 nursing consultants, 1 corporate regional director were not associated to the facility which poses an immediate health and safety risk to residents in care.

87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement was not as evidenced by: Based on interviews, the licensee failed to ensure that R1’s door was functioning, which posed a potential health and safety risk to persons in care.

This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as eight (8) facility staff were not associated to work in the facility and one (1) facility staff did not receive a fingerprint clearance and/or background check prior to working in the facility which poses an immediate health and safety risk to residents in care.

87207 False Claims. No...employee of a licensee shall make or disseminate any false or misleading statement...This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above.The Facility Resident Services Director stated she faxed incident report to the Regional Office on 08/11/2021, however, the Investigator learned that a substitute nurse filled in for the Director at the facility on 08/10/2021 and 08/11/2021, which posed an immediate health and safety risk to residents in care.

87464(f)(1) Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision...This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. (R1) was not provided the proper supervision to ensure R1’s safety. R1 had a history of falls, which led to multiple falls causing R1 to sustain injuries requiring hospitalization, which posed an immediate health and safety risk to residents in care.

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate...This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. R1’s Services Plan dated 07/24/2021 was not updated after R1 sustained multiple falls requiring hospitalization, which posed an immediate health and safety risk to residents in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1)(B) Any serious injury...occurring while the resident is under facility supervision.This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. R1 had a fall on 08/07/2021 and 08/16/2021 sustaining injuries which required hospitalization, no incident reports were received for the incidents, which posed a potential health and safety risk to residents in care.

Based on interview and record review, the licensee did not comply with the section cited above in 3 counts which poses an immediate health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above in 4 counts which poses an immediate health, safety or personal rights risk to persons in care.