Oak Cottage of Santa Barbara Memory Care

The investigation found deficiencies related to resident safety and freedom of movement, specifically citing the restriction of residents with dementia. Two Type A citations were issued concerning the failure to provide adequate wandering space and the restriction of resident movement. The facility was instructed to immediately correct these issues and implement staff retraining.

The inspection was an unannounced Case Management – Incident visit conducted to address a self-reported incident from 11/6/2/2025. The analyst reviewed documents, video footage, and interviewed the administrator. No deficiencies were noted during the visit.

The unannounced case management visit focused on a death that occurred on 6/29/2025. The primary deficiencies cited relate to failure in timely and complete incident reporting. Specifically, the facility failed to submit required written reports for multiple falls experienced by the resident, including a fall on 6/25/2025, which constitutes an immediate risk to resident safety.

The facility underwent an unannounced required Annual Inspection. The initial assessment noted several positive observations regarding fire safety, cleanliness, and resident activities. The report concludes with a statement that no deficiencies were cited during the exit interview.

This complaint investigation found multiple substantiated allegations related to resident safety and compliance. Specifically, deficiencies were cited regarding inadequate supervision, failure to follow proper eviction procedures, and delayed reporting of suspected abuse. All cited deficiencies were classified as Type A, indicating immediate health and safety risks.

The facility underwent an unannounced required Annual Inspection. The physical environment was generally observed to be in good repair, and the LPA noted positive aspects regarding cleanliness, safety equipment, and resident activities. No deficiencies were cited during the visit.

This report details a complaint investigation concerning a resident elopement due to inadequate supervision. One deficiency was cited under CCR 87468.2(a)(4) as a Type A violation, indicating an immediate health risk. A secondary Type B deficiency was also cited regarding the failure to ensure proper supervision, necessitating staff retraining on elopement policies.

The investigation identified multiple deficiencies across two separate complaint allegations. The most severe finding was a Type A citation regarding the inappropriate administration of PRN medications, posing an immediate health risk. Additionally, two Type B citations were issued concerning failures in personal rights, specifically related to improper diapering practices.