Inspection visit

Follow-up on correctionsApril 21, 2022

OAK COTTAGE OF SANTA BARBARA MEMORY CARELicense 4258021182 citations on this visit

2 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analysts (LPAs) Olson and Kontilis conducted an unannounced visit to the facility. While investigating complaint # 29-AS-20210614172310, LPA Kontilis noted the following deficiencies. Resident 1 (R1)’s care plan was not updated timely after multiple changes in condition. R1 sustained sixteen falls in five months. Records obtained do not indicate R1’s care plan was updated after the first thirteen falls, and was only updated on 5/21/2020 and 5/22/2020. After the fall on 2/26/2020, R1 was diagnosed with a dislocated hip. Medical records indicate R1 was provided a knee immobilizer/brace and was discharged the next day back to the facility. Medical records instruct R1 to wear the knee immobilizer at all times for one week, until R1 follows up with an orthopedic surgeon. R1’s care plan was not updated to include these new instructions from the hospital regarding the knee immobilizer/brace. After the fall on 5/21/2020, R1 was again diagnosed with a dislocated hip following the witnessed fall on 5/20/2020. Medical records indicate a knee immobilizer/brace was placed on R1 and “staff at Oak Cottage notified of plan of care.” Instructions indicate to use the knee immobilizer for a few days to prevent recurrent dislocations. R1 was also given a wedge pillow from the hospital and instructions to use it to keep R1’s legs from being crossed. R1’s care plan was not updated to include the knee immobilizer/brace nor the wedge. In the facility’s Progress Notes, there are multiple entries showing R1 did not have the wedge in place and R1 kept removing the wedge. On 5/26/2020, Progress Notes indicate at 2:00am, R1 was observed with the wedge not in place and the leg brace was on incorrectly according to S4. Progress Notes indicate S4 showed S7 the correct way to put the brace on and how to place the wedge. In addition, on 2/11/2020 R1 was noted to be “anxious pacing up and down the halls and exit seeking” and on 2/22/2020, R1 continued exit seeking behavior but R1’s care plan was not updated to indicate this new behavior. On 2/23/2020, staff noted R1 was “in wheelchair most of the day to avoid falls.” R1’s physician’s report was not updated to indicate R1 was using a wheelchair nor to indicate exit seeking behavior. Based on the information obtained, the facility did not update R1’s care plan after multiple changes in condition. Continued on 809-C During a tour related to the complaint on 4/19/2022, LPA Kontilis observed an electric tea kettle plugged in Room # 213. Generations Program Director (GPD) removed the tea kettle from the room during the visit at 2:46pm. Exit interview, deficiencies cited on 809-D, report emailed, appeal rights emailed.

Citations

7 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

87303(a)Type B
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.
87466Type A
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.
87468.2(a)(4)Type A
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.
87463(a)Type B
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.
87705(d)Type B
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.
87468.1(a)(2)Type A
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.
87307(a)(3)(D)Type B
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.

FAQ · About this visit

Common questions about this visit

What happened during the April 21, 2022 inspection of OAK COTTAGE OF SANTA BARBARA MEMORY CARE?

This was an other inspection of OAK COTTAGE OF SANTA BARBARA MEMORY CARE on April 21, 2022. 2 citations were issued: 2 Type B.

Were any citations issued to OAK COTTAGE OF SANTA BARBARA MEMORY CARE on April 21, 2022?

Yes, 2 citations were issued (0 Type A, 2 Type B). The first citation was for: "87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Mainten..."

What type of inspection was this?

This was an other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated June 8, 2026. If you believe any information is inaccurate, report it here.

Follow-up on corrections·April 21, 2022