425801995-3-2-2026-29-AS-KBUY-DSK5SS-20260326201314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425801995
Report Date: 03/02/2026
Date Signed: 03/02/2026 02:35:24 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2026 and conducted by Evaluator Kristin Kontilis

COMPLAINT CONTROL NUMBER: 29-AS-20260218172426

FACILITY NAME:	ALEXANDER GARDENS		FACILITY NUMBER:	425801995
ADMINISTRATOR:	LEICHTER, MITCHELL		FACILITY TYPE:	740
ADDRESS:	2120 SANTA BARBARA ST		TELEPHONE:	(805) 682-9644
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93105
CAPACITY:	36	CENSUS: 24	DATE:	03/02/2026
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Mitch Leichter, Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Resident eloped from the facility due to lack of staff supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA met with Administrator Mitch Leicter and explained the purpose of the visit. LPA Kontilis conducted the initial visit on 2/25/2026 from approximately 12:21 pm to 4:15 pm at which time Long Term Care Ombudsman (LTCO) Diane See accompanied LPA during the visit. From approximately 12:40 pm to 4:15 pm, LPA conducted interviews and obtained documents pertaining to the investigation.
On the allegation, Resident eloped from the facility due to lack of staff supervision: Reporting Party voiced concern for Resident 1’s (R1’s) safety. Reporting Party reported that R1 left the facility on foot “entirely unsupervised”, R1 walked on public streets to their private residence without facility intervention, supervision, or awareness. Reporting party further reported that R1 was located at the family residence at which time, the family member returned R1 to the facility. Interviews conducted revealed R1 was active and repeatedly tried to exit through the facility front door on 2/6/2026 at approximately 2:30 pm. Records reviewed and interviews conducted revealed R1’s family had been notified of R1’s exit-attempting behavior. Interviews conducted
Please continue to 9099-C, Pg 2.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20260218172426

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALEXANDER GARDENS	FACILITY NUMBER: 425801995
	VISIT DATE: 03/02/2026

NARRATIVE

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and records reviewed revealed that when R1’s family member arrived at the facility at around 3:05 pm, R1 was not in their room; the staff began to search the property but R1 could not be found. R1’s family member contacted others at the family home approximately 1.6 miles away at which time it was discovered that R1 had arrived at the private residence on foot and alone. Interviews conducted revealed staff did not recall R1’s elopement however, record review revealed written documentation to verify staff was notified in writing of R1’s elopement. Interviews conducted revealed staff try to redirect residents who cannot leave unassisted; Residents’ pendants alert staff if they go off the property, and available caregivers will try to locate the resident. It is unclear if R1 was wearing their pendant or if the pendant alerted staff when R1 left the property. Record review revealed R1’s Physician’s Report (LIC 602) states R1 has a diagnosis of Aphasia and cannot leave the facility unassisted; and, R1’s Physician was informed of the elopement. Interviews conducted and records reviewed revealed staff could not determine how R1 eloped from the facility. Since the incident, Staff have implemented additional safety checks for R1. Based on records reviewed and interviews conducted, the allegation that Resident eloped from the facility due to lack of staff supervision is deemed Substantiated at this time.

The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code.

Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20260218172426

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALEXANDER GARDENS	FACILITY NUMBER: 425801995
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/02/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/04/2026 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4)… residential care facilities for the elderly shall have all of the following personal rights: 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.	1 2 3 4 5 6 7	Administrator agrees to provide written plan as to safety measures that will ensure Residents do not leave the facility without supervision.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the licensee did not comply with the section cited above when Resident 1 (R1) eloped from the facility alone and without supervision which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026

LIC9099 (FAS) - (06/04)

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