405800577-12-13-2022-29-AS-DCHZ-CM3SDH-20221213124711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800577
Report Date: 12/13/2022
Date Signed: 12/13/2022 12:48:29 PM

Document Has Been Signed on 12/13/2022 12:48 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:	VILLAGE AT SYDNEY CREEK, THE		FACILITY NUMBER:	405800577
ADMINISTRATOR:	KIRK P KLOTTHOR		FACILITY TYPE:	740
ADDRESS:	1234 LAUREL LANE		TELEPHONE:	(805) 543-2350
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	84	CENSUS: 54	DATE:	12/13/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Kirk Klotthor, Administrator		TIME COMPLETED:	01:00 PM

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On 12/13/22 at 10:36 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced visit to the facility to investigate an incident reported by the facility. LPA met with Kirk Klotthor, Administrator, and explained the purpose of the visit.

On 12/11/22 at 8:53 pm, the administrator emailed an Unusual Incident/Injury Report (LIC 624) to the LPA. The Incident Report states that, on 12/11/22 at 4:25 pm, staff entered the room of Resident #1 (R1) and found R1 in their bed unresponsive. Paramedics were called, and per the administrator, R1 had committed suicide.

On 12/13/22 at 10:40 am, LPA toured R1’s room. It is a single occupancy room with a locked door. Administrator states residents who are able to lock/unlock their doors are given keys and that R1 was given a key.

At 10:45 am, LPA interviewed the administrator. The administrator states that he heard from his staff that R1’s family told staff that R1 had tried to commit suicide prior to residing in the facility and that helium may have been used. He states that the family wanted the resident in a locked facility due to R1’s dementia and that R1 couldn’t take care of themselves. Administrator states he was involved in the resident assessment prior to R1 moving in. Administrator states that R1’s doctor visited on 12/9/22 and assessed R1 to determine whether R1 did, in fact, have dementia. Administrator says it was a concern that was brought up either by R1 or the Long-Term Care Ombudsman and says that the doctor did not provide the new assessment or revised Physician Report (LIC 602) to the administrator.

At 11:40 am, LPA interviewed Staff #1 (S1). S1 states that R1’s family visited “often, at least five times.” S1 says the family wanted a better quality of life for the resident and that R1’s family said R1 had previously tried to commit suicide but did not foresee this happening again. S1 says the family did not provide specifics about the attempt. S1 says R1 was very jovial and engaged in facility events and a joy to have around.

Continued on 809-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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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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: VILLAGE AT SYDNEY CREEK, THE	FACILITY NUMBER: 405800577
	VISIT DATE: 12/13/2022

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At 11:50 am, LPA interviewed Staff #2 (S2). S2 states that R1 had a “fun, great personality, and often said they were happy.” S2 says R1 participated in a lot of facility and community events. S2 says prior to R1 moving in, R1’s family told S2 that R1 had called 911 and told them they wanted to commit suicide. S2 says this potentially happened in Summer 2022 and no details were given beyond this from the family. S2 says the management team discusses potential admits and that they did not see a concern with R1 since R1 “convinced” staff that R1 was in a good place and the incident was in the past. S2 states that R1 was in counseling as referred by R1’s physician.

No deficiencies cited at this time. Exit interview conducted and report emailed to administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

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