405800577-4-7-2022-29-AS-KBUY-CDXW22-20220429165333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800577
Report Date: 04/07/2022
Date Signed: 04/07/2022 06:35:14 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
03/30/2022 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20220330120349

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: 46	DATE:	04/07/2022
		UNANNOUNCED	TIME BEGAN:	05:09 PM
MET WITH:	Derek Cox, Med-tech, and Trisha Maliwanag, Med-tech		TIME COMPLETED:	06:45 PM

ALLEGATION(S):

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Staff are not wearing masks while present in the facility

INVESTIGATION FINDINGS:

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On 4/07/2022 at 5:09 pm, Licensing Program Analyst (LPA) Chavez conducted a 10-day unannounced complaint investigation. LPA met with Staff #2 (S2) and Staff #3 (S3) and explained the purpose of the visit.

Regarding the allegation “Staff are not wearing masks while present in the facility,” the complainant’s concern was that two caregivers working in the facility were observed not wearing face coverings. To investigate the allegation, LPA interviewed a credible witness, the administrator and staff, and toured the facility.

On 3/29/2022 at 1:35 pm, a credible Witness #1 (W1) observed Staff #4 (S4) in neighborhood one not wearing a mask while in the direct vicinity of residents in care. Staff #5 (S5) was also observed not wearing a face covering while working in the medication room.

On 4/07/2022 at 5:09 pm, LPA arrived at the facility and was not screened upon entry or at anytime during the visit.
Continued on 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 29-AS-20220330120349

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: 04/07/2022

NARRATIVE

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On 4/07/2022 at 5:15 pm, LPA interviewed Staff #1 (S1) who revealed that the receptionist is responsible for ensuring all staff and visitors wear masks upon entry, and when the receptionist is not present, management is responsible. LPA observed a central entry point for staff and visitors; however, there is access to the facility through the kitchen as well. LPA interviewed Staff #2 (S2) who stated that all staff are required to wear surgical masks and that “everyone is responsible” for making sure all staff are wearing a mask. S2 stated that the only time staff do not wear masks is when eating and drinking in the breakroom. S2 also said that staff take their masks off temporarily in the facility to get a drink. At 5:33 pm, LPA spoke with Administrator Kirk Klotthor by phone. Administrator says all staff and visitors are required to wear masks. The exception, he says, is when a resident does not understand staff, then staff will temporarily take their masks off when talking with residents.

On 4/07/2022 at 5:35 pm, LPA toured the facility and observed all staff present wearing masks.

Based on observations, the allegation “Staff are not wearing masks while present in the facility,” is deemed Substantiated. LPA interviewed credible witness and staff and made observations. The facility did not protect the personal rights of residents in care to be able to receive safe and healthful accommodations in that the facility staff failed to wear face coverings while providing care and supervision to residents in care and visitor was not screened upon entry. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions.

Pursuant to Title 22, California Code of Regulations, the deficiency will be cited on 9099-D.

Exit interview conducted, deficiency cited, a copy of this report and appeal rights 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: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20220330120349

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 04/14/2022 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1 Personal Rights. Residents have the right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will hold infectious control training, review and train staff on all recent PIN’s released for 2022, including mask-wearing mandated, and provide copy of training and staff signatures to CCL by 4/14/22.
	8 9 10 11 12 13 14	Based on observations, the facility failed to ensure staff were wearing face coverings which poses an immediate health, safety and personal rights 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.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC9099 (FAS) - (06/04)

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