Incident investigation·October 28, 2025

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management incident visit to the facility. On 10-15-2025, LPA Kontilis received a telephone call from Administrator Emily Gerr and Licensee Lisa Gerr requesting guidance from LPA Kontilis regarding an incident that occurred in the facility. The date of the incident was not stated. Licensee Lisa Gerr stated a resident (Resident 1/R1) has alleged that a staff member (Staff 1/S1) punched/hit R1 while conducting a brief change with R1. Licensee Gerr stated this was an unusual allegation as S1 has worked at the facility for a while and Licensee believes this is out of character for S1. Licensee stated while an internal investigation looking into the matter is currently being conducted, S1 is on administrative leave. Licensee inquired as to when S1 can return to work once the investigation has been completed. LPA responded by saying that her questions cannot be answered until further information is obtained and a Report of Suspected Dependent Adult/Elder Abuse (SOC341) is submitted to CCLD. On 10/23/2025, CCLD received SOC341 Report of Suspected Dependent Adult/Elder Abuse from Santa Barbara Police Department stating on 10/15/2025, Santa Barbara Police Officer McGowan, Badge #27543, responded to a telephone call from Administrator Emily Gerr. Administrator Emily Gerr stated R1 told her that S1 punched R1 and R1 no longer wanted to live in the facility. During today’s visit, LPA obtained documents pertaining to the incident and conducted an interview with Administrator. R1 and S1 were unavailable at the time of the visit. Administrator Emily Gerr stated on 10/16/2025, Gerr submitted SOC341 Report of Suspected Dependent Adult/Elder Abuse to CCLD and Long Term Care Ombudsman (LTCO) via “fax app” on her mobile phone. Please continue to 809-C, Pg 2. Gerr further stated she assumed the fax was received but was surprised that no one had gotten back to her about the incident. LPA confirmed with Administrator Gerr that the SOC341 report was not received by CCLD until 10-23-2025 via an outside agency. Due to time restraints, LPA will return at a later date to continue the investigation. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit.