405800577-7-28-2022-29-AS-KBUY-CH5V6V-20220809161008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800577
Report Date: 07/28/2022
Date Signed: 07/28/2022 05:16:05 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
09/23/2020 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20200923110447

FACILITY NAME:	VILLAGE AT SYDNEY CREEK, THE		FACILITY NUMBER:	405800577
ADMINISTRATOR:	KIRK P KOTTHOR		FACILITY TYPE:	740
ADDRESS:	1234 LAUREL LANE		TELEPHONE:	(805) 543-2350
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	84	CENSUS: 42	DATE:	07/28/2022
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Lisa Hulse, Vice President		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff are not conducting fire drills

INVESTIGATION FINDINGS:

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On 7/28/22 at 10:35 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced complaint investigation visit to the facility above. LPA met with Lisa Hulse, Vice President, and explained the purpose of the visit.

On the allegation “Facility staff are not conducting fire drills,” the complainant was concerned that the licensee has not had a fire drill in 18 months and reports that there was a real fire at the facility and “staff did not know what to do.” To investigate the allegation, LPA interviewed the administrator and staff, and reviewed records.

On 9/25/20 at 2:59 pm, LPA spoke with Kirk Klotthor, Executive Director/Administrator. Mr. Klotthor reports there have never been any evacuations or fires, and that the last time they had a fire drill, he says “I don’t even remember.” He explains that the “maintenance guy does the fire drills.”

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: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

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-20200923110447

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: 07/28/2022

NARRATIVE

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On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed three staff. Staff say they have attended training on fire drills and there have been some impromptu fire drills. They state this happens between monthly and every 3-4 months. One staff stated “we have not had one this year.” Another staff stated they were not familiar with who was responsible for evacuating which residents.

On 7/22/22 between 9:55 am to 10:45 am, LPA interviewed two staff. Staff report there are approximately three fire drills per year and that the maintenance manager conducts them. Further, that the maintenance manager takes staff around the facility and shows them were the fire extinguishers and exits are located. They state that on one occasion, the fire department came out to show them how to evacuate, and on another occasion, “the Alpha Fire guy came and did a demonstration with staff on putting out a fire.”

On 7/28/22 at 11:00 am, LPA interviewed the Maintenance Manager who stated that a fire occurred in the laundry room of the facility in 2020. At 12:28 pm, LPA interviewed part-time maintenance staff who stated that there was a fire in the laundry room in July 2020. Maintenance staff does not remember the exact date and specifies that the Wellness Coordinator contacted them at 12:05 am on that day. Maintenance staff arrived at 12:20 am to find the fire department finishing up. Staff says the sprinkler above the dryer put out the fire.

On 7/28/22 at 11:26 am, LPA reviewed the training sign-in sheets for fire drills. Between July 2019 and September 2020, fire drill training was conducted on 7/11/19, 11/14/19, 3/12/20, and 6/18/20. The first three trainings were conducted four months apart. LPA reviewed the staff schedule dated 9/24/20 which lists 83 staff, 41 of which are direct care staff. LPA compared this with the list of attendees for each training. At the 7/11/19 training, 14 out of 41 direct care staff attended (34% attendance); at the 11/14/19 training, 19 of 41 care staff attended (46% attendance); at the 3/12/20 training, 27 of 41 care staff attended (66% attendance); and, at the 6/18/20 training, 26 of 41 staff attended (64% attendance). Trainings were not attended by all direct care staff.

Based on the evidence obtained, the allegation “Facility staff are not conducting fire drills,” is deemed Substantiated at this time. The facility did not conduct fire drills at minimum once every three months with, at minimum, all direct care staff on each shift attending the training as required with facilities caring for residents with dementia. Deficiency cited on the LIC 9099-D.

Exit interview conducted, deficiency cited, and a copy of the report and appeal rights emailed to the Vice President and the Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200923110447

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: 07/28/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/02/2022 Section Cited CCR 87705(I)(8)	1 2 3 4 5 6 7	87705(I)(8) Care of Persons with Dementia: (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (8) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Vice President has committed to ensuring fire drills are conducted at minimum every three months with at minimum all direct care staff. Attendance will be documented on training sign-in sheets. Vice President has read the regulation and submit a Statement of Understanding to CCL by 8/02/22. Vice President has agreed to discuss the requirements with management to ensure it is being taken care of.
	8 9 10 11 12 13 14	Based on interviews and record review, the facility did not ensure that, at minimum, all direct care staff were trained on fire drills at minimum every three months which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
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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: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC9099 (FAS) - (06/04)

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