Oak Cottage of Santa Barbara Memory Care

Dignity in personal relationships

General hygiene items required

87705(f)(5) Care of Persons with Dementia: Interior and exterior space shall be available on the facility premises to permit residents with dementia to wander freely and safely.This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited when they restricted two residents from freely moving about the facility, which posed an immediate health, safety, and personal rights risk to residents in care.

Dignity in personal relationships

87468.1(a)(1) Personal Rights of Residents in All Facilities: (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons: This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when S1 was observed rough handling R1 on video, which posed an immediate health, safety, and personal rights risk to residents in care.

Report specified resident events within seven days

87211(a) Reporting Requirements: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement is not met as evidenced by:Based on record review, the licensee did not comply with the section cited above as CCL did not receive incident reports regarding R1’s falls including a fall that occurred on 6/25/2025, which poses an immediate health, safety, or personal rights risks to residents in care.

87224(c) Eviction Procedures. The licensee shall, in addition to either serving the required 30 days’ notice…or seeking approval from the Department and service 3 days’ notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited when they issued a verbal eviction for R1 to be removed from the facility, which posed an immediate health and safety risk to residents in care.

Right to sufficient care and qualified staff

87468.2(a)(4) Personal Rights…Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights…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 record review, the licensee did not comply with the section cited when staff did not provide adequate supervision to R1 resulting in aggressive incidents, which posed an immediate health and safety risk to residents in care.

Report suspected non-serious physical abuse within 24 hours

87211(c) Reporting Requirements: Any suspected physical abuse that does not result in serious bodily injury...shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required…This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when staff did not report resident on resident abuse for 11 days, which posed an immediate health and safety risk to residents in care.

Obtain required California clearance or exemption

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

Report specified resident events within seven days

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)...This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when a medication error of 12 residents occurred on 6/30/2024 and not reported until 7/19/2024 which poses a potential health and safety risk to residents in care.

Give PRN medication by physician order

87465(c)(2) 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.

Right to sufficient care and qualified staff

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on interviews and records reviewed Licensee did not ensure supervision was provided to R1; as a result R1 eloped from facility.

Right to sufficient care and qualified staff

87468.2(a)(4) Additional Personal Rights. 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, the licensee did not comply with the above cited section when they double diapered residents, which posed a potential health and safety risk to residents in care.

Give PRN medication by physician order

87465(c)(2) 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 interviews, the licensee did not comply with the above cited section when they did not follow physician’s orders for R1’s PRN, which posed an immediate health and safety risk to residents in care.

Maintain facility in clean, safe, sanitary condition

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 interviews, the licensee did not ensure the rooms and bathrooms were clean from urine and feces, which posed a potential health and safety risk to residents in care.

Store centrally held medications in locked secure place

87465(h)(2) Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: Based on observation, the licensee did not comply with the above cited section when LPA observed the medication cart was unlocked and unattended, which posed an immediate health and safety risk to residents in care.

Right to sufficient care and qualified staff

…Residents…have all of the following personal rights: 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, the licensee did not ensure resident’s incontinence care needs were met, which posed a potential health and safety risk to residents in care.

Notification to department after hospice care starts

87632(d)(2) Hospice Waiver: The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. This requirement is not met as evidenced by:Based on records review, the licensee did not comply with the section cited above as CCL did not receive hospice notifications for approximately 15 residents placed on hospice from 1/20/2022 to 1/31/2023 which poses a potential health and safety risk to residents in care.

Auditory exit monitoring for elopement risk

87705 Care of Persons with Dementia. In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia. This requirement was not met as evidenced by: Based on observation, the facility did not ensure residents with dementia did not have access to an electric tea kettle, which posed a potential health and safety risk to residents in care.

Update reappraisal at required intervals

87463(a) Reappraisals. 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 was not met as evidenced by: Based on interviews and record review, the facility did not ensure R1’s appraisal was updated to reflect significant changes, which posed a potential health and safety risk to residents in care.

Right to sufficient care and qualified staff

…Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 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 record review, the licensee did not ensure R1 received care, supervision, and services to meet R1’s needs, which posed an immediate health and safety risk to residents in care.

Regular observation and documentation of resident changes

87466 Observation of the Resident. The licensee shall ensure…residents are regularly observed for changes in physical, mental, emotional…social functioning…appropriate assistance is provided when…observation reveals unmet needs...changes such as...deterioration of...physical health condition are observed, the licensee shall ensure that…changes are documented…brought to the attention of the resident's physician…the resident's responsible person...This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure R1 was observed for changes in condition and R1’s physician was notified timely, which posed an immediate health and safety risk to residents in care.

Safe, healthful, comfortable accommodations

87468.1(a)(2) Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure R1 was accorded safe, healthful and comfortable accommodations due to the numerous falls and injuries sustained, which posed an immediate health and safety risk to residents in care.

General hygiene items required

87307(a)(3)(D) Personal Accommodations and Services: …The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: Hygiene items of general use such as soap and toilet paper. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure toilet paper was provided to 2 out of 2 residents (R1, R2), which posed a potential health and personal rights risk to residents in care.

Maintain facility in clean, safe, sanitary condition

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 met as evidenced by: Based on interviews, the licensee did not ensure the rooms and bathrooms of R1 and R2 were clean from urine and debris, which posed a potential health and safety risk to residents in care.