Office review·October 30, 2025

On 10/30/2025, an Informal Conference was held at the Goleta Office. In attendance included Licensing Program Manager (LPM) Kelly Burley, Licensing Program Analyst (LPA) Kristin Kontilis, Administrator Robert Glock, and Wellness Director Tina Tran. The purpose of this Informal Conference is to discuss complaint investigation 29-AS-20241001130402. A general compliance review of the facility was also discussed. The facility was licensed on 03/24/2023 and the current census is 101. The Administrative Action process was explained to the licensee representatives, as well as the role of an informal conference. On 10/01/2024, the RO received a complaint alleging facility staff did not answer Resident 1 (R1’s) call button in a timely manner, resulting in the resident sustaining a fracture. R1 required assistance with care needs, and the investigation revealed although Staff 1 (S1) claimed R1’s call for assistance, they did not respond. R1 was unattended to for hours, resulting in R1 falling and sustaining a facial laceration, hematoma, and wrist fracture. During today’s conference, the licensee representatives discussed the strategies they’ve employed in order to maintain compliance with Title 22 Regulations. Licensee representatives discussed measures they had implemented to address changes in condition with R1, additional care monitoring, and other resources to address R1’s needs, particularly overnight. They also discussed additional oversight measures for their signal system, as well as additional trainings on staff communication. Strategies also included monthly medication audits and daily compliance checks with their updated electronic medical record system. The licensee representatives were again notified of the potential for Administrative Action, including a civil penalty of $10,000 for serious bodily injury, which is still under review. Should it be determined that the civil penalty will be issued, the licensee will be notified. Exit interview conducted and copy of today's report was provided to the licensee representatives.