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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800577
Report Date: 05/18/2023
Date Signed: 05/18/2023 02:27:37 PM


Document Has Been Signed on 05/18/2023 02:27 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, THEFACILITY NUMBER:
405800577
ADMINISTRATOR:KIRK P KLOTTHORFACILITY TYPE:
740
ADDRESS:1234 LAUREL LANETELEPHONE:
(805) 543-2350
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:84CENSUS: 65DATE:
05/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Carolyn Stewart, LVNTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Chavez conducted a subsequent case management visit to deliver findings for an incident reported by the facility on 12/11/22. LPA met with Carolyn Stewart, LVN, and explained the reason for the visit.

On 12/11/2022, the administrator emailed an Unusual Incident/Injury Report (LIC 624) to Community Care Licensing (CCL). The Incident Report stated that on 12/11/2022 at 4:25pm, 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 12/13/2022, from 10:36am to 1:00pm, LPA Chavez conducted an unannounced visit to the facility to investigate the incident reported by the facility. LPA met with Kirk Klotthor, Administrator, and explained the purpose of the visit. From 10:40am to 11:50am, the LPA toured R1’s room, conducted interviews with Administrator and staff, and requested documents pertinent to the investigation. LPA determined further investigation was needed. On 12/14/2022, the case was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Maria Barragan.

Investigator Barragan conducted interviews on 12/15/2022, at approximately 3:22pm, with Detective Dustin Phillips of the San Luis Obispo (SLO) Coroner’s office; on 12/19/2022, at approximately 4:08pm. and on 12/21/2022, at approximately 11:03am, contact with Lieutenant Chad Pfarr of the SLO Police Department; on 01/04/2023, at approximately 9:04am, with R1’s resident representative; on 01/12/2023, from approximately 10:40am to 1:55pm, with the Executive Director/Administrator, facility Licensed Vocational Nurse (LVN), staff and residents; on 01/17/2023, at approximately 1:01pm, with the SLO Long Term Care Ombudsman (LTCO); on 01/23/2023, from approximately 5:34pm to 5:55pm, with staff; on 02/05/2023,



Continued on 809-C.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
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 3


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: 05/18/2023
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at 11:20am, with staff; on 02/15/2023, at approximately 8:33am, and 03/10/2023, at approximately 8:56am, contact with the SLO Coroner’s office. In addition, the investigator reviewed facility file documents related to R1, SLO PD report, SLO County Sheriff’s Department report, Emergency Medical Services (EMS) report, 911 audio recording, medical records, and home health records.

Based on the review of R1’s records, R1 was admitted to the facility in September 2022. R1’s primary diagnosis was dementia. R1 was also diagnosed with A-Fib, BPA, Diabetes II, and GERD. R1 had a history of being verbally abusive, depressed, and suicidal. R1 was able to communicate their needs, was ambulatory and able to take care of activities of daily living (ADLs) independently. R1 did not require special observation or night supervision and had no observable safety awareness deficits. R1 was cooperative, social, but expressed feelings of sadness. The facility was aware R1 had previously attempted to commit suicide, but R1 had been cleared by their physician prior to moving in. Per the Administrator, R1 did not exhibit signs of self-harm nor did they express thoughts of suicide during the time that they lived at the facility.

A review of medical records revealed on 12/09/2022, another physician met with R1 to conduct a cognitive/functional evaluation as resident expressed wanting to move from the dementia unit to assisted living. R1 admitted he had been severely depressed, but only for a few months after their suicide attempt prior to moving into the facility. Based on the assessment, the physician did not see any signs of dementia and R1 had no suicide plan or thoughts of self-harm.

According to the SLO County Sheriff’s report, on 12/11/2022, at approximately 4:42pm, Deputy Knowles was dispatched to the facility for a coroner investigation. Upon arrival, the Deputy met with SLO Police Department law enforcement personnel. Upon entering R1’s room, he observed R1 lying supine on a twin bed. R1 had a plastic bag over their head that was drawn closed with a blue cord around their neck. R1’s feet were bound together with a belt and R1’s hands were bound with a black cord behind their back. The autopsy and CT scanned performed on R1 revealed no signs of trauma or foul play noted. Facility staff advised they had seen R1 walking around the facility at approximately 1:00pm. The facility med-tech entered R1’s room at approximately 4:25pm and found R1 and called 911.

Continued on 809-C.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 05/18/2023
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SLO Fire EMS responded to the facility but noted that R1 was already dead. R1 was pronounced dead at 4:36pm due to rigor mortis. Multiple facility staff were interviewed. It was reported that R1 had tried to commit suicide before but failed and called 911 for assistance. After that attempt, R1’s resident representative placed R1 at the facility where they resided since 09/20/2022. Facility staff stated R1 was not happy living at the facility because R1 felt they did not belong in a facility for residents with dementia. R1 was high functioning and mobile, unlike other residents in the facility.

Based on the totality of the investigation, statements obtained, R1’s prior suicide attempt, no evidence of foul play or trauma to R1’s body, and a suicide note found on R1’s laptop written on the day R1 died, it was determined by the investigating law enforcement personnel that R1 had likely committed suicide. The autopsy and CT scan performed on R1 revealed no signs of trauma or foul play. Based on statements from facility staff, LTCO, and a review of medical records, R1 was high functioning, and R1’s needs were met. R1 was depressed but did not express thoughts of hurting self. R1’s resident representative stated facility staff took great care of R1 and R1’s health improved during the time that they lived at the facility. R1’s resident representative stated R1 was determined to kill self and it was no one’s fault. No citations will be issued at this time.

Exit interview conducted and report given.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
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