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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421702848
Report Date: 04/28/2026
Date Signed: 04/28/2026 05:00:21 PM

Document Has Been Signed on 04/28/2026 05:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:COVENANT LIVING AT THE SAMARKANDFACILITY NUMBER:
421702848
ADMINISTRATOR/
DIRECTOR:		MARJAN ALBERTFACILITY TYPE:
741
ADDRESS:2550 TREASURE DRIVETELEPHONE:
(805) 687-0701
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY: 379CENSUS: 329DATE:
04/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Marjan Albert, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection visit at the above-named facility. Upon arrival, LPA was greeted by Marjan Albert, Administrator and Scott Bigler, Associate Executive Director and explained the purpose of the visit.
The facility is a 16-acre Residential Care Facility for the Elderly (RCFE) Continuing Care Retirement Community. It consists of Independent Living, Assisted Living, and Memory Care. The skilled nursing facility is not within Community Care Licensing Division’s jurisdiction. The Independent Living section has approximately 218 private residential apartments. The Assisted Living unit has approximately 36 residential apartments. The Memory Care unit consists of a secure unit with approximately 16 apartments.
The facility has a hospice waiver for 10 residents. Currently, there are five (5) residents on hospice.
Resident’s activities address the “eight dimensions of holistic wellness”. These activities include but are not limited to fitness programming, life-long learning, art classes, religious studies, book clubs, technology education, spiritual programming, inter-generational opportunities with students in local schools, music appreciation and participation, outdoor games such as bocce ball, corn toss, ping pong; a Residents’ Counsel, and scenic drives to museums, parks, and cultural centers.
There are four dining areas and eateries on the campus. The outdoor area consists of a 25-meter swimming pool with a jacuzzi in a locked fenced area, a gym, fitness studio, putting green, walking paths, botanical garden, coy pond, and shaded sitting areas conducive for outdoor visitations.
The administrative offices consist of a two-story building with Sales & Marketing, Human Resources, Transportation, a bank, Director of Philanthropy, Business Office Specialist, Resident Life Director, and Office of Executive Administrative Assistant, Executive Director and Associate Executive Director.

Please continue to 809-C, Pg 2.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Kristin Kontilis
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COVENANT LIVING AT THE SAMARKAND
FACILITY NUMBER: 421702848
VISIT DATE: 04/28/2026
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 The facility has a daily check-in process for Residential Living residents. A daily follow-up check-in is conducted if a resident has not “checked-in”.
Administrator and Associate Executive Director certificates are valid. Staff files reviewed had health screenings, current first aid certificates, and all required trainings.
Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medical Accounting Records (MARs).
At approximately 2:54 pm, medication review revealed Resident 1’s (R1’s) morning medication Amlodipine 2.5mg tablet had one extra tablet and R1’s Escitalopram 5mg medication had one extra tablet. Further, LPA reviewed a self-reported incident wherein Resident 2 (R2) was “mistakenly” administered seven medications prescribed to another resident on 1/7/2026.

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 via email.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Kristin Kontilis
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/28/2026 05:00 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 04/28/2026 at 04:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COVENANT LIVING AT THE SAMARKAND
FACILITY NUMBER: 421702848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
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
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Based on interview and record review, the licensee did not comply with the section cited when R1 had an unexplainable overcount of two medications and R2 was administered medications prescribed to another resident which posed an immediate health and safety risk to residents in care.
POC Due Date: 04/30/2026
Plan of Correction
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Licensee agrees to conduct a training with all Qualified Medication Assistants to include no predating medication bottles and to ensure proper safe open, start date noted on the prescription bottles, and the six rights of medication administration. Administrator agrees to submit written statement to LPA with dates of training to be held, description, trainer, and trainee. Written documentation will be provided to LPA via email no later than POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Kristin Kontilis
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2026


LIC809 (FAS) - (06/04)
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