WESTMONT OF SANTA BARBARA

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(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 observation and interviews conducted, the Licensee did not comply with the regulation above by restricting access to the Concierge's desk and/or denying freedom of choice which poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agrees to no longer rope off areas restricting access and/or freedom of choice in common areas of the facility. Civil Penalty Assessed

Deadline recorded: Aug 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(c)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator immediately removed the confidential document from the file. Deficiency cleared at the time of the visit.

Deadline recorded: Sep 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Type A: 87465(c)(2) Incidental and Medical Care: ....Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 08/28/2025 Plan of Correction Administrator agrees to conduct a staff in-service to include proper procedure in administering medications and properly documenting transactions. Administrator will provide in writing the date in-service was conducted including description of the training, first and last names of attendees, and attendees’ signatures.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator agrees to have carpets cleaned in five (5) resident's rooms no later than POC due date (11/15/2024). Administrator agrees to provide photographs of cleaned carpets via email on or before POC due date (11/15/2024).

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement 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..

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Acting Executive Director agrees to conduct all-staff trainings no later than due date (7/30/2024). Acting Executive Director agrees to submit proof of training via email to LPA no later than 7/30/2024. Proof of training to LPA via email to include first and last name and signature of trainee, descriptions of training, dates completed, and duration of training.

Official classification

Type A

Official code

87506(b)(17)(A)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal; This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 07/27/2024 Plan of Correction Acting Executive Director agrees to provide an updated appraisal for R10 no later than POC due date of 7/27/2024.

Official classification

Type A

Official code

87465

Regulation authority

CCR

What the official deficiency says

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 is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 07/27/2024 Plan of Correction Acting Executive Director stated S1 is no longer employed with the facility. Acting Executive Director agrees to submit a written plan to ensure residents will receive their medication as prescribed.

Official classification

Type A

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

87465(h)(4) Incidental Medical and Dental Care: All centrally stored medications shall be labeled and maintained in compliance with state and federal laws… This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 07/27/2024 Plan of Correction Acting Executive Director agrees to provide proof that R1’s Centrally Stored Medication Record reflects all prescribed medications.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Acting Executive Director agrees to provide proof via email that the patio areas have been cleaned.

Official classification

Type B

Official code

87211(g)(1-3)

Regulation authority

CCR

What the official deficiency says

87211(g)(1-3) Reporting Requirements: The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: (1) Name and residence and mailing addresses of the new administrator. (2) Date he/she assumed his/her position. (3) Description of his/her background and qualifications, including documentation of required education and administrator certification. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Licensee shall submit required paperwork to CCLD via email naming Administrator to the facility. Required paperwork to be submitted no later than the POC due date (7/27/2024).

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Interim Administrator agrees to provide a written plan to ensure residents’ physicians are notified of medication refusals promptly and appropriately. Interim Administrator agrees to conduct in-service with staff to include procedures to follow with residents' medications refusals. Interim Administrator will inform CCLD as to date(s) in-services will be conducted.

Deadline recorded: Jul 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Acting Executive Director agrees to provide proof S1 was retrained in mediation procedures. Acting Executive Director agrees to submit a written plan to ensure residents will receive their medication as prescribed.

Deadline recorded: Jul 3, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Acting Executive Director agrees to provide a written incident reports, as well as a written statement of understanding of 87211 Reporting Requirements.

Deadline recorded: Jul 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

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: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 09/15/2023 Plan of Correction Administrator agrees to provide written proof of medication administration in-service to all staff who are responsible for administering medications. Written proof to include date of in-service, sign-in sheet of attendees (first and last name w/signature), description of in-service, and plan of action to adhere to regulation as stated above.

Official classification

Type A

Official code

87506(c)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator agrees to conduct an in-service with facility staff to maintain compliance with HIPAA regulations and will keep the residents' records confidential. Administrator will provide in-service training documents to LPA via email no later than 7/19/2023.

Deadline recorded: Jul 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee agrees that staff will not work or be present in this facility without an appropriate transfer to the facility. Staff 1 (S1) was associated at the time of the visit. This page has been amended. Civil Penalty assessed in the amount of $3,000.

Deadline recorded: May 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator agrees notify all staff to wear masks at all times in the facility. Administrator agrees to conduct an infectious control training, review and train staff on all recent PIN’s released for 2022, ncluding mask-wearing mandates, and provide copy of training and staff signatures to CCL by 12/22/2022. List of attendees with signatures to include first and last name of each attendee shall be provided to LPA via email.

Deadline recorded: Dec 22, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee agrees that staff members, home care agency staff, nurse consultants, and corporate staff will not work or be present in this facility without an appropriate transfer to the facility. Civil Penalty assessed in the amount of $12,600.

Deadline recorded: Dec 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(1)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(1) Criminal Record Clearance. (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or criminal record exemption... or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 08/05/2022 Plan of Correction Licensee agrees that staff members will not work at this facility without an appropriate transfer and/or receiving a criminal background/fingerprint clearance. Civil Penalty assessed in the amount of $4,750.

Official classification

Type A

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee will submit plan how you will ensure Reappraisals are conducted in a timely manner when there is a change in resident condition. Submit to CCL by 4/1/22

Deadline recorded: Apr 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87207

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee has agreed to do the following: 1. Schedule a training on conduct inimical and false claims. Training must be conducted by an approved vendor. 2. 2. Submit a letter to CCLD indicating the vendor's name, address, phone number, and date of the training. Training must take place by

Deadline recorded: Apr 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee will review 87211 Reporting Requirements regulation and submit a memo of understanding regarding submitting incident reports timely to appropriate parties. Submit to CCL by 4/5/22

Deadline recorded: Apr 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 02/16/2022 Plan of Correction Administrator removed staff from the facility and schedule. Administrator will hold an in-service for directors and submit training log to LPA by 2/16/22

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) 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) or This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 02/16/2022 Plan of Correction Administrator removed staff from the facility and schedule. Administrator will hold an in-service for directors and submit training log to LPA by 2/16/22