405800577-2-8-2024-29-AS-KBUY-D2W3WU-20240228173718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800577
Report Date: 02/08/2024
Date Signed: 02/08/2024 05:36:19 PM

Unsubstantiated

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
12/21/2022 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20221221173142

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: 60	DATE:	02/08/2024
		UNANNOUNCED	TIME BEGAN:	01:34 PM
MET WITH:	Lisa Hulse, Vice President		TIME COMPLETED:	05:50 PM

ALLEGATION(S):

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Facility does not have enough staff to meet residents’ needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver final findings for the above allegation. LPA Chavez interviewed Administrator on 12/28/22 and 12/30/22, requested and reviewed documents on 12/28/22. LPA Olson interviewed Staff on 2/8/24 and requested relevant documents. During today’s visit, LPA met with Vice President and explained the reason for the visit.

On the allegation: Facility does not have enough staff to meet residents’ needs. It was alleged that on 12/17/22 there was one employee in Neighborhood 2, which has approximately 15 residents. Administrator states in Neighborhood 1 there are 20 residents and 3 staff on AM and PM shifts, 1-3 staff on the NOC shift; Neighborhood 2 has 16 residents, 3 staff on AM and PM, and 1-3 staff on NOC; and Neighborhood 3 has 15 residents,1 concierge, 2 staff on AM and PM shift and 1-3 staff on NOC. LPA observed the schedule for 12/17/22 and observed 8 total staff scheduled for AM and 7 total staff scheduled for PM.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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-20221221173142

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: VILLAGE AT SYDNEY CREEK, THE	FACILITY NUMBER: 405800577
	VISIT DATE: 02/08/2024

NARRATIVE

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LPA Chavez interviewed Administrator on 12/28/22 who stated Life Enrichment staff conduct activities throughout the day, help feed residents and do outings but don’t give baths/showers. Administrator stateed that MedTechs are available if residents refuse a shower more then once and if the resident continues to refuse the facilities LVN may step in to assist. Administrator states the facilities have Concierge staff that are available, if needed to help with feeding and bathing but must be supervised.

LPA Chavez toured the facility on 12/28/22 and observed 3 caregivers in each Neighborhood. LPA observed residents appeared neat with no malordors. On 1/29/24, LPA Olson toured Neighborhood 2 and 3. LPA Olson observed 3 staff in each neighborhood and residents’ appearance did not indicate a severe lack of staff. On 2/8/24 LPA Olson interviewed Staff regarding sufficient staff and if residents needs are being met. Interviews revealed sometimes there are only two staff scheduled in each Neighborhood but never just one. Most staff interviewed worked here in December 2022 and remember it being lighter then normal and less staff than usual, but no staff remembered situations where resident's needs weren't met. Staff interviewed stated sometimes after 8pm there is only one staff in the neighborhood but most residents are in bed and it's not a problem. Staff indicated it is possible to meet all the needs of residents with two staff but they prefer and all stated it's easier when there are 3 or more staff. All staff interviewed stated residents needs are always met and there is always someone they can call to help if needed. If the Neighborhood is short staffed residents may not get a shower during that shift but it is always made up the next day.

Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC9099 (FAS) - (06/04)

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