<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800577
Report Date: 10/29/2020
Date Signed: 10/29/2020 04:10:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME:VILLAGE AT SYDNEY CREEK, THEFACILITY NUMBER:
405800577
ADMINISTRATOR:KIRK P KOTTHORFACILITY TYPE:
740
ADDRESS:1234 LAUREL LANETELEPHONE:
(805) 543-2350
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:84CENSUS: 53DATE:
10/29/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Lisa Hulse, Vice President/Backup AdministratorTIME COMPLETED:
02:37 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/29/2020 at 2:25 pm, Licensing Program Analyst (LPA) Chavez conducted a case management visit to issue a deficiency. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s case management investigation was conducted telephonically with Lisa Hulse, facility Vice President and back-up administrator. LPA explained the purpose of today’s visit.

On 10/13/2020, LPA reviewed the facility’s license and a current resident roster and observed that the facility currently has 16 residents on hospice but only had a hospice waiver approved for 8. LPA phoned administrator to ascertain the reason they retained more hospice residents than their hospice waiver was approved for. Administrator stated he believed their hospice waiver was for 16 residents. The administrator could not provide documentation that a hospice waiver for 16 residents was approved and could not provide documentation that a previous request for hospice waiver increase was sent to CCL. Based on the information obtained, the facility exceeded their hospice waiver for 8 residents by having 16 residents on hospice.

At 2:37 pm, a telephonic exit interview was conducted with Lisa Hulse, and an electronic copy of the report and deficiencies was emailed for signature to be returned to LPA Chavez.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) -59-343
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: 805-450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117

FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE
FACILITY NUMBER: 405800577
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2020
Section Cited

1
2
3
4
5
6
7
87632(a) Hospice Waiver
(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department.
This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on record review, the administrator did not comply with the regulation listed above. The administrator did not ensure the facility stayed within the maximum number of approved hospice residents or submit a request to increase the quantity of hospice residents allowed in the facility.
8
9
10
11
12
13
14

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.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) -59-343
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: 805-450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2